CRT Q&A: Was appropriate use's makeover enough?

WASHINGTON, D.C.—The American College of Cardiology announced a major change to the appropriate use criteria lexicon, with descriptions of "appropriate," "may be appropriate" or "rarely appropriate" (as opposed to "appropriate," "uncertain" and "inappropriate") for procedures or the use of imaging in certain populations. J. Jeffrey Marshall, MD, sat down with Cardiovascular Business during the Cardiovascular Research Technologies (CRT) meeting to discuss the implications of the changes.

CVB: What was the initial purpose for the appropriate use criteria [AUC]?

Marshall: AUC, along with other decision-making tools such as the guidelines and door-to-balloon, all serve to help physicians make the correct choices for each of the patients. AUC was originally created by the Radiological Society of North America (RSNA) to measure what steps were appropriate for ordering imaging tests.

It is a great idea, but the problem has arisen from the lexicon. Everything we do is under a microscope, so the payers, the public and, in particular, patients view how physicians are making decisions. The original lexicon was extracted from the RAND Corporation for industrial manufacturing process, and that doesn’t accurately translate for medicine. "Inappropriate" has a negative connotation when dealing with the care of human beings. The Society for Cardiovascular Angiography and Interventions [SCAI] has been advocating changing the lexicon for a while, but folks were initially hesitant to violate the RAND criteria.

Specifically, why is the lexicon problematic in medicine?

There is a sacrosanct space inside the exam room between a doctor and a patient. Those decisions are the art of medicine. They can be measured by AUC somewhat, but are a limited number of scenarios. As the population continues to age, we are going to see more and more unique, elderly situations. For instance, I treated an 88-year-old patient with multivessel disease who was on maximum medication and felt terrible, but just needed one lesion fixed. She was a previously active person, who simply wanted to continue swimming. Where does the AUC fall in a patient case like that?

In addition to the limited number of scenarios, you can’t translate something that is a nuanced art into a fixed situation.

Are you pleased with the recent changes in the AUC lexicon?

They are a great start. The AUC process is an awkward adolescent. It is a relatively new but important idea, but it hasn’t been validated very well. So, the new AUC terminology sends the right message. Except for some rare exceptions, physicians are always trying to perform appropriate procedures and order appropriate tests, but sometimes these decisions fall into a gray zone. Inappropriate was just not an accurate term for medical decision-making.

Was the change in lexicon enough?

We also need more clinical scenarios in the AUC, and more research looking at the AUC process. There is a concern that the AUC could actually push the pendulum too far the other way. If we underuse certain procedures or tests, we could harm patients. Unfortunately, the underserved populations, along with minorities and women, tend to experience underuse the most. Doing less isn’t necessarily always the best path.

Marshall is the president of SCAI, an interventional cardiologist with the Northeast Georgia Heart Center and medical director of cardiac cath labs at Northeast Georgia Medical Center in Gainesville, Ga.