ACC: AUC guidelines helpful, but need work

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CHICAGO—While appropriate use criteria (AUC) documents were created with the intent to help deliver high-quality care, there is much room for improvement, said Fredrick A. Masoudi, MD, associate professor of medicine in the division of cardiology at the University of Colorado in Denver, March 26 during a presentation at the 61st annual American College of Cardiology (ACC) scientific session.

“The question that remains is how do we delivery high-quality, high-value-based care to our patients?”said Masoudi. “We have heard a lot about guidelines and there is no doubt that guidelines are critically important to figuring out this issue of how we will deliver high-quality care.”

However, Masoudi cautioned that guidelines, while helpful, rarely focus on costs. He noted that the current healthcare system is unsustainable in terms of costs. And while it is hard to define the exact point of unsustainability, he said that healthcare reform strives to curb and restrain these high costs.

He also cited data from the Dartmouth Atlas Study that showed a 10-fold variation between the lowest referral regions and highest utilization referral regions in PCI use. “There is a marked and sustainable variation in the use of expensive cardiovascular procedures,” Masoudi noted.

He cited Donald Berwick, former administrator of the Centers for Medicare & Medicaid Services (CMS), when he said: “Unintended variation is stealing healthcare blind.”

While Masoudi said that most in healthcare realize this, "In the background of attempting to apply evidence-based care, we are fighting a game that is not going to last at its current pace.”

There are a variety of strategies to restrain healthcare costs, he noted; however applying the “old haircut approach,” may be the most detrimental. This strategy involves the mantra that “we are not going to make any decisions, we are not going to engage ‘rationing,’ we are just going to say ‘we are going to spend less on healthcare.' This approach won’t work."

And while he commended the ACC and American Heart Association’s efforts to employ guidelines to help clinicians deliver value-based care, he said that they miss the mark in attempting to strategize attempts to cut costs.

“Different documents help us to deliver the use of effective therapies, decrease use of inappropriate therapies and stop potentially harmful therapies to improve patient outcomes,” he added. “Increasing patient outcomes and reducing the cost of healthcare delivery does not include just clinical practice guidelines, but also performance measures.”

It is often hard to apply specific guidelines to the patient in the room and some variation of care is warranted, said Masoudi. “We don’t want to apply the same approach to every patient. That is not personalizing medical care.”

However, he said that it remains unknown as to how much of the variation within PCI is unwarranted.

“We acknowledge that AUC guidelines are not perfect,” Masoudi offered. “No one is saying that in the correct rate of procedures designated as inappropriate that zero percent is the correct level.”

He acknowledged that after studying PCI procedures deemed “inappropriate” in the context of the AUC guidelines, some often seem appropriate.

“Appropriate use guidelines are created with the intent to improve the quality of care we deliver to patients; however, they are not perfect,” he said. “There is work that we need to do to make appropriate use documents better.”

He ended saying that AUC guidelines are an important first step to the delivery of quality care.