ACC Corner | How Three Descriptions Affect Appropriateness of Care

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 - Robert C. Hendel, MD, FACC
Robert C. Hendel, MD, FACC

The American College of Cardiology (ACC) released changes to the process for developing appropriate use criteria (AUC), including frequently misinterpreted terminology for describing the levels of appropriateness of care. Updated in February 2013, appropriate use of procedures or imaging for specific populations now are described as “appropriate,” “may be appropriate,” or “rarely appropriate.”

The criteria always were intended to be used clinically and for quality improvement in ways that allow for physician judgment and the measurement of patterns of use over time. The changes help to more accurately convey the original intent of ACC in developing AUC standards and will be applied in development of all subsequent AUC. There have been changes made to the AUC process used by the ACC over the seven years it has been in use, including the introduction of a formal review process prior to rating, administration of a survey of professional expertise for rating panel balance and establishment of a relationships-with-industry policy. Appropriate use topics are now being broadened to cover multiple tests or procedures at once for a specific disease or clinical presentation.  Future documents will more often rate all techniques that might be relevant to a patient’s condition.

The AUC are developed by more than 50 professionals representing various stakeholders involving a multidisciplinary approach. Scenarios are crafted based on practice experience, matched against clinical trials, reviewed by a wide range of experts and then graded for appropriate use. New terminology and definitions include:

  1. Appropriate Care: An appropriate option for management of patients in this population due to benefits generally outweighing risks; effective option for individual care plans, although not always necessary, depending on physician judgment and patient-specific preferences.
  2. May Be Appropriate Care: At times an appropriate option for management of patients in this population due to variable evidence or agreement regarding the benefit/risk ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient based on additional clinical variables and judgment along with patient preferences.
  3. Rarely Appropriate Care: Rarely an appropriate option for management of patients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option.

Prior to the updated terminology, the ACC’s AUC Task Force surveyed 975 healthcare professionals and other stakeholders to help gauge current knowledge, use and potential avenues for improving the understanding, clarity and utilization of AUC.  The majority of providers viewed improved care delivery, education and cost reduction as the primary benefits of AUC. The most often identified benefit, by 54 percent, was to improve decision-making by practitioners in day-to-day clinical care.

Most participants (92 percent) felt that professional discretion is intrinsic to clinical decision-making and that AUC are not a substitute for clinical judgment, which is also explicitly stated in all of the AUC documents. The preponderance of those surveyed (93 percent) also felt that the “uncertain” category should be reimbursed all or some of the time, in agreement with AUC statements. The intent of the AUC is to allow for clinical judgment across all categories and determine the frequency for which the procedure may be an option, not a requirement for good care.

Moving forward, there is room for improvement in understanding of AUC methodologies in some areas. The College will continue to educate health plans and other regulatory bodies about the benefits of AUC, put AUC directly in the hands of providers and ensure appropriate testing. Through these efforts and other programs, the College will continue to promote optimal patient care.

Dr. Hendel is chair of the AUC Writing Committee.