Is it time to re-examine appropriate use terminology?

While appropriate use criteria (AUC) have been integrated in interventional cardiology for the past few years, many physicians have expressed concerns that the terminology fails to accommodate nuanced physician judgment. Tony Farah, MD, chief medical officer at West Penn Allegheny Health System in Pittsburgh, sought to contextualize the AUC among other decision-making processes for Cardiovascular Business.

The AUC has been firmly entrenched in the practice of the interventional cardiologists for nearly the past two years at West Penn Allegheny, but Farah, an interventional cardiologist by training, encourages his cardiologists to view the AUC among the varied armamentarium of decision-making options in treating a very diverse patient population.

He said that the most clear-cut treatment options lie on the extremes of the "appropriate" and "inappropriate" designations. “The closer that you get to those patients who fall in between the distinction of ‘appropriate’ and ‘inappropriate,’ and if you add in other variables, such as functional or anatomic variables, then it becomes a necessary discussion between the patient and the interventional cardiologist,” said Farah, who added that physicians need to consider multiple patient-related considerations, such as their preferences and their physical activity.

“If you present the pros and cons to the patients, given their very individualized circumstances," the ultimate outcome will be a better informed decision, he said. “It’s not always an easy decision for either the physician or the patient—but the physicians’ job is to explain that a patient’s particular case may present a gray zone, and to discuss the viable options, even if they are not taken into account in the AUC.”

This population of gray-zone patients is fairly large, according to Farah.

Taking this need for physician judgment into consideration, Farah recognized that the fellows and physicians at West Penn Allegheny are sensitive to the fact these quality measures, like AUC, may ultimately be used as a stick, which will make them cautious.

It might come down to terminology. “The term ‘inappropriate’ might be misconstrued, especially when it comes to clinical decisions that are not as clearly defined—where the physicians and the patients truly should have more input,” said Farah, who acknowledged that some cases have been and continue to be clearly inappropriate.

“However, when it comes to regulators, the media or payers—either the government or private payers—we as physicians don’t want to be inappropriately penalized if clinical decisions are made as a result of a discerning process with the patient.” This type of exposure could adversely impact patient care by stunting a physician's ability to use his or her judgment, he added, and creates uncertainty in patients’ minds with respect to their treatment options.

While there have been hints that the professional societies are re-examining the terminology, Farah, who is not a part of that discussion, said that it would be beneficial to clinical practice if the medical community can agree on terminology that will not mislead the patient, while simultaneously making it easier for regulators and payers to understand the criteria.

To combat the confusion that has resulted from AUC, Farah also said that the Society of Cardiovascular Angiography and Interventions (SCAI) has taken several steps to make it easier on the interventional community to navigate these waters in practice, such as the SCAI Quality Toolkit and the Accreditation for Cardiovascular Excellence (ACE). West Penn Allegheny, which is a five-hospital system, is currently accredited by ACE at one of its two cath lab sites while pursuing accreditation for the second.