Adoption of the Coronary Artery Disease-reporting and Data System: Reduced Downstream Testing and Cardiology Referral Rates in Patients with Non-obstructive Coronary Artery Disease

Abstract

IntroductionThe coronary artery disease-reporting and data system (CAD-RADS) was developed to standardize communication of per-patient maximal stenosis and provide treatment recommendations that may affect downstream testing.MethodsDownstream testing, cardiology referral, and cost were abstracted for 1,796 consecutive patients undergoing coronary CT angiography (CCTA) before and after the adoption of the CAD-RADS reporting template at a single-center closed referral hospital system. Cost analysis was based on direct invasive and non-invasive testing utilizing the Center for Medicare & Medicaid Services (CMS) outpatient prospective payment system (OPPS) final rule for 2018.ResultsBaseline cardiovascular risk factors were balanced between the groups. Overall, referrals for downstream testing were similar between cohorts (10.7% vs 10.8%; p = 0.939). Referral for downstream testing was reduced in the CAD-RADS 1 & 2 cohort compared to non-obstructive coronary artery disease (CAD) by non-standardized reporting (NSR; 5.1% vs 14.4%, p < 0.001). This was offset by more non-diagnostic scans in the CAD-RADS cohort (9.7% vs 4.2%, p < 0.001), resulting in increased downstream testing (28.8% vs 11.4%, p = 0.038). Overall, cardiology referral rates by primary care providers (PCPs) were similar between the groups (12.2% vs 15.8%, p = 0.197). Cardiology referral rates were increased among patients with non-obstructive CAD in the NSR cohort compared with CAD-RADS 1 & 2 patients (20.5% vs 8.6%, p = 0.021). Referrals for invasive coronary angiography were low in both groups overall (3.5% vs 3.2%, p = 0.726). Median downstream testing costs were similar between the groups (p = 0.554).ConclusionsAdoption of the CAD-RADS reporting template was associated with a reduction in downstream testing and cardiology referral rates among non-obstructive CAD (CAD-RADS 1 & 2) patients. Thus, CAD-RADS may impact downstream testing in patients in whom further testing can typically be deferred.

CAD-RADS™ 2.0 – 2022 Coronary Artery Disease – Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI)

“…The purpose of this document is to update the first version of the CAD-RADS (13) standardized classification of coronary artery disease for patients undergoing CCTA that was originally published in 2016 in order to include additional features such as plaque burden and ischemia, and to incorporate evidence from recent clinical trials as well as new clinical practice guidelines. The updated 2022 CAD-RADS referral rates in patients with non-obstructive coronary artery disease (22) and has a favorable impact on medical therapy and systolic blood pressure control (23). Finally, recent studies have validated the performance of deep learning algorithms for the evaluation of CAD-RADS classification on CCTA (24).…”