Effect of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve on Physicians' Clinical Behavior　- Differences Between Sites With and Without Appropriate Use Criteria as Designated by the Japanese Reimbursement System.

Background: Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFR _CT ) is an established tool for identifying lesion-specific ischemia that is now approved for use by the Japanese insurance system. However, current clinical reimbursement is strictly limited to institutions with designated appropriate use criteria (AUC). This study assessed differences in physicians' behavior (e.g., use and interpretation of FFR _CT , final management) according to Japanese AUC and non-AUC site designation. Methods and Results: Of 5,083 patients in the ADVANCE Registry, 1,829 from Japan were enrolled in this study. Physicians' behavior after interrogating CCTA and FFR _CT was analyzed separately according to AUC and non-AUC site designation. Compared with AUC sites, patients referred for FFR _CT from non-AUC sites had a higher rate of negative FFR _CT , less severe anatomic stenosis, and a slightly lower rate of management plan reclassification (51.2% vs. 61.3%), with near-identical utility in both groups. Actual care corresponded equally well to post-FFR _CT plans in both groups. The likelihood of revascularization for positive or negative FFR _CT was similar between the 2 groups. Importantly, AUC and non-AUC sites were equally unlikely to revascularize patients with negative FFR _CT and stenosis >50% or patients with positive FFR _CT and stenosis <50%. Conclusions: Compared with AUC sites, non-AUC sites had lower disease burden and reclassification of management plans, but nearly identical clinical integration. Actual care corresponded equally well to post-FFR _CT recommendations at both sites.
Competing Interests: H.M. declares speaker fees from Abbott Vascular Japan, Phillips, Zeon Medical, Boston Scientific Japan. H.O. declares payments for lectures, including service on speakers bureaus, from HeartFlow Inc. N.T. declares consulting fees from Abbott Vascular Japan, Boston Scientific Japan and KANEKA Medix Co. C.R. is an employee of and has equity in HeartFlow. G.R. has received an institutional research grant from HeartFlow. L.M.H.K. has received departmental grant funding from Siemens Healthineers, HeartFlow, Verily, and Mallinckrodt. B.L.N. has received institutional unrestricted grants from Siemens and HeartFlow. J.L. declares consultant and stock options with CIRCLE CVI and HeartFlow, and research support from GE Healthcare. H.I. is a member of the Editorial Board of Circulation Reports. Y.M. is an Associate Editor of Circulation Reports. The remaining authors declare no conflicts of interest.
(Copyright © 2020, THE JAPANESE CIRCULATION SOCIETY.)