To apply more appropriate labels to utilization norms, new terminology has been approved for the American College of Cardiology Foundation's (ACCF's) Appropriate Use Criteria (AUC). Starting with the next set of AUC scheduled for release in February 2013 and covering the use of implantable defibrillators, future criteria will be categorized as Appropriate, Maybe Appropriate and Rarely Appropriate. This replaces the original AUC terms: Appropriate, Uncertain and Inappropriate.

In an AUC Methodology Update, published in the Journal of the American College of Cardiology (JACC) on Feb. 22, the AUC Task Force notes that the categorical nature of the original AUC terminology "often led to misperceptions by all stakeholders about when a procedure may be considered for a patient."

Peter L. Duffy, MD, FACC, was one interventionalist who came to believe that use of the term "inappropriate" was itself inappropriate. "I think it's really important that we get rid of that term," said the director of cardiovascular quality at Reid Heart Center, Pinehurst, NC. "There are always cases where we all agree that while the AUC says it's inappropriate, in specific patients or specific situations it is appropriate."

Dr. Duffy was a speaker at the ACC's recent Cardiovascular Summit: Solutions for Thriving in a Time of Change. One of his sessions was entitled, "Is It Ever Appropriate to Be Inappropriate?" As he said, "I can't tell you the number of conversations I have had with third party payers who say 10 percent of someone's work is 'inappropriate' based on the Appropriate Use Criteria.”

He currently is leading a team of six interventionalists who are reviewing 11 hospitals for the appropriateness of some 400 cases. He noted many of the cases reported as 'inappropriate' really are not, given that most peer reviewers agreed they would have chosen to do the same in that situation even in variance with AUC.

Using the old AUC categories, Dr. Duffy said, that rather than the 10 percent rate of inappropriate use reported by stakeholders, reviewers would find 1 – 2 percent of cases inappropriate, based on the documentation provided. "It does not mean that it is clearly, for sure, absolutely, inappropriate," he said, "but that the documentation we were able to get did not support the choice made."

The lesson: clearly document why clinical decisions are made, especially when the choice departs from AUC. Dr. Duffy said during a CV Summit session, "Proper documentation is very important because in many of the cases I have reviewed it's not easy to figure out exactly what happened."

A Tool, Not a Grade

Pamela S. Douglas, MD, a past president of the ACC and a member of the AUC Task Force, said at the Cardiovascular Summit, "Appropriate Use Criteria were not intended to grade you as a good doctor or a bad doctor. They are intended to be tools to help you become a better doctor. Because to improve your quality you first have to know where you stand and then you can improve it. They are quality improvement tools and not meant to second guess you in an individual patient decision."

A good illustration of AUC use that is not punitive but rather used for practice improvement is the ACC's Imaging in FOCUS initiative, a Web-based system designed to help practices use AUC at the point of care to ultimately reduce rarely appropriate imaging. FOCUS offers the ability to perform quick appropriate use checks at point of order when clinicians are deciding whether or not to order a test. This is quite different from after-the-fact tracking . "Up to this point," said Dr. Douglas, "I am not aware of much in the way of point-of-order decision tools. Most everything is on the back end, after you have done the angioplasty and the idea is to see what you did." That comes across as more judgmental than the FOCUS approach, which is 'Here's some information to help you make the right decision prospectively.'

Dr. Douglas said the goal of FOCUS is to reduce inappropriate imaging by 15 percent in one year and by 50 percent within three years. Importantly, she said the goal is "across the population of participants, so it is not punitive; it's a group goal and not about my decisions and your decisions."

Currently, the network encompasses more than 700 sites with more than 13,000 cases in the registry. Sites that have completed the FOCUS action plans have reduced their rarely appropriate use by half. "That's a real-world application of AUC and a positive performance improvement quality improvement mode, rather than a slap on your wrist," she added.

Other AUC Changes

The change in AUC terminology is just one of the refinements to AUC methodology summarized in the paper to be published in JACC. Since the first document was published, other changes have included:

• Document Name: Originally called Appropriateness Criteria, the change to AUC reflects the more active function of the documents in promoting evidence-based, effective use of cardiovascular technologies.
• Appropriateness Topics: The AUC initiative has expanded from imaging to devices and procedures, including coronary revascularization, diagnostic catheterization, implanted cardiac defibrillators, and cardiac resynchronization devices.
• Process: The entire AUC process has undergone refinement, including enlarging the size of the writing group, an even more extensive external review of indications, expanding the composition of the rating panel, and more formalized components of the rating panel process.

A coauthor of the new paper, Dr. Douglas said the changes will improve the value of AUC. She noted that the American College of Cardiology Foundation, along with imaging subspecialty societies and other organizations, developed the first set of Appropriate Use Criteria in 2005. Compare that, she said, to the first ACCF clinical guidelines, published about 35 years ago. AUCs are "a young document and we’re still learning how to use it."

Keywords: Quality Improvement, Documentation, Catheterization, Defibrillators, Implantable, Cardiac Resynchronization Therapy

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