In medicine, there are cases in which most physicians could decide instantaneously which procedure would be best for the individual patient at hand, and then there are times when physicians are on the fence and turn to clinical practice guidelines to help their decision-making.
The American College of Cardiology (ACC) and American Heart Association (AHA) have been creating clinical guidelines for more than 25 years. The guidelines provide a foundation for summarizing evidence-based cardiovascular care, and—where there is evidence lacking—provide expert consensus. However, variability still remains, raising questions of over- or under-use.
Appropriate use criteria (AUC) are decision support quality improvement tools intended to help clinicians select the right patients for the right diagnostic tests and procedures, and provide a practical standard upon which to better understand variability. Yet, there is room for improvement. In the case of AUC, there are times when what’s best for an individual patient isn’t deemed appropriate and what is deemed appropriate isn’t best for the individual patient.
As the field of medicine rapidly changes, it remains a challenge to stay current with new and evolving sciences. Over the years, the ACC has seen a need for “living documents” that rapidly respond to the changing evidence created from randomized clinical trials or even from the ACC’s National Cardiovascular Data Registry (NCDR).
Under the direction of Alice K. Jacobs, MD, chair of the ACCF/AHA Task Force, clinical guidelines have become timelier through focused updates and are more congruent with related guidelines. These practices have minimized the risk of discordant recommendations between guidelines simply due to the timing of the updated cycle. The 2012 AUC coronary revascularization update reflects such changing science learned from the SYNTAX trial in addition to assessing other clinical scenarios not originally evaluated in the first 2009 AUC document (J Am Coll Cardiol 2012;59:857-881).
Full integration of the ACC’s quality improvement tools has been a goal of the college for several years, and we are seeing this become a reality in an effort led by the ACC’s Wisconsin Chapter. The “SMARTCare” program addresses documented clinical quality, resource use and cost variation in treatments of stable ischemic heart disease. The program is a collaboration among members of ACC’s Wisconsin Chapter, integrated healthcare systems, business coalitions, measurement and data collaborative groups and other statewide, multi-stakeholder collaborative groups.
Many concerns and questions remain about AUC, such as relationships with clinical outcomes in their application and negative unintended consequences. Recent editorials—“The Privilege of Self-Regulation, the Role of AUC” (J Am Coll Cardiol 2011;57:1557-1559) and “PCI Use in the United States: Defining Measures of Appropriateness” (J Am Coll Cardiol Intv 2012;5:229-235)—offer food for thought as we move forward implementing new science and technology.
Important ongoing studies also are now assessing the application of AUC with looking at midterm cardiovascular clinical outcomes while closely evaluating the potential for negative or unintended consequences. Professional societies such as the ACC need not only educate members of the value of AUC implementation in their practice, but also—perhaps even more importantly—aggressively educate patients, the media, payors and purchasers to the proper use and caution for misuse of AUC assessments.
The AUC task force is continuously faced with new challenges, but the cardiovascular community is privileged to be able to measure ourselves against one another as we strive for the best outcomes for our patients.
Dr. Brindis is past president of the ACC.