ACC Corner | Debunking the AUC Myths

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The cardiovascular community has come a long way over the past eight years with the development of appropriate use criteria (AUC). To understand why these criteria are important to our daily practice, we must remember why the concept was first developed.  

More than a decade ago, usage statistics for diagnostic imaging were shown to have the fastest growth among all Medicare-covered services. At the same time, health plans in California were starting to review and question PCI and CABG cases based on the RAND appropriateness criteria developed during the 1990s. The American College of Cardiology (ACC) Medical Directors’ Institute, as well as leaders from its board of governors, saw this as both a challenge and an opportunity to look at over- and under-utilization of procedures.

The ACC provided guidance regarding appropriate use criteria (AUC) of cardiovascular procedures by creating an Appropriateness Criteria Working Group. The group published a document on a proposed method for evaluating the appropriateness of cardiovascular imaging followed by the first AUC document in 2005, the “American College of Cardiology Foundation [ACCF]/American Society of Nuclear Cardiology Appropriateness Criteria for SPECT Myocardial Perfusion Imaging.”

Upon completion, the ACC held a summit to gather feedback on the process and how it might be improved. This information was used to refine the process, including introducing an early review of proposed clinical scenarios, larger expert panels, more comprehensive lists of clinical scenarios and ongoing coordination with clinical guidelines and other ACC policy documents. To date, the ACC has developed AUC for echocardiography, cardiac CT, cardiac MR, cardiac radionuclide imaging, peripheral arterial and venous ultrasound, coronary revascularization and diagnostic catheterization. Currently under development are documents on implantable defibrillators and cardiac resynchronization, ultrasound use in pediatric patients and multimodality imaging use in heart failure, chest pain and stable ischemic heart disease.

AUC help to define “when to do” and “how often to do” a given procedure, taking into consideration the context of scientific evidence, a particular healthcare setting, a patient’s profile and a physician’s judgment. The criteria can help inform individual patient care decisions, but are best used to evaluate patterns of care by physicians over time. All the criteria are developed by panels of clinical experts from the ACCF and its partner organizations based on evidence and, when necessary, expert opinion. The panels assess the benefits and risks of a procedure for different indications or patient scenarios and then determine whether the indication is appropriate, uncertain or inappropriate.

It is important to note that AUC ratings often contain more detailed scenarios than the recommendations covered in practice guidelines and, thus, subtle differences are possible. The criteria also are based on current understandings of technical capabilities and potential patient benefits of the procedures examined. Future evidence development will require these ratings to be updated on a regular basis.  In general, the documents have been updated every one to two years with all except the cardiac MR AUC having been revised at least once since their original publication.

I wrote in a 2004 President’s Page in the Journal of the American College of Cardiology that, “some may not see the importance of the College’s efforts to address appropriateness. Some might argue that explicit guideline performance indicators can be divisive and prefer we not enter this arena. However, if we do not lead in this effort, others may set criteria that may not be wise either for us as physicians or for our patients.” Eight years later, I believe the same scenario rings true. (Although looking at today’s use of radiology benefit management companies, I would change the last part of the sentence to “others WILL set criteria.”)

It is our duty as a profession to work together with policy makers, payers and other medical societies to ensure patients are receiving the most appropriate care, while also reducing unnecessary healthcare costs and limiting wide variations in care delivery. This is about “doing the right thing” and is best done by our own standards based on the latest science.

Dr. Wolk is past president of the American College of Cardiology.