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.