Session at ASNC2012 Explores the Global Impact and Implementation of AUC

More than a decade ago, usage statistics showed diagnostic imaging to have the fastest growth among all medical services covered by Medicare. This procedural growth and geographic variation has slowed in recent years, with a number of factors contributing to this decline including the development of appropriate use criteria (AUC). The topic of AUC and their global impact and implementation was covered during a hot session on Sept. 8 at the American Society of Nuclear Cardiology's (ASNC) annual conference in Baltimore.


AUC are intended to define "when" and "how often" to perform a given procedure in the context of scientific evidence, the health care environment, the patient's profile and a physician's judgment. While the criteria can help inform individual patient care decisions, they are best used to evaluate patterns of care by physicians over time. The first AUC for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI)  were published in October 2005, and have since been followed by AUC for echocardiography, cardiac computed tomography, cardiac magnetic resonance (CMR) imaging, peripheral arterial and venous ultrasound, cardiac radionuclide imaging, coronary revascularization and diagnostic catheterization. Currently, AUC on implantable defibrillators and cardiac resynchronization, ultrasound use in pediatric patients, and multi-modality imaging use in heart failure, chest pain, and stable ischemic heart disease are under development.

"Although the initial focus of AUC was on cardiac imaging, it has since expanded to other procedures," said, Robert Hendel, MD, FACC, moderator of the ASNC AUC session and chair of the ACC's Imaging in FOCUS work group. According to Hendel, the benefits of AUC are that they are transparent, developed by doctors, and include benchmarking and feedback reports to help improve performances. Other non-AUC options, such as radiology benefit managers (RBMs), lack these benefits and can have negative economic impacts on practices because they are so labor intensive. RBMs, in particular, are incentivized for reducing volume and costs, noted Hendel. Because of this, they are more focused on "putting the brakes on testing" than determining what is most appropriate for the patient. According to Hendel, the millions currently spent on third-party RBMs could be saved by using programs like ACC's Imaging in FOCUS initiative instead.

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Raymond Gibbons, MD, FACC, professor of medicine at the Mayo Clinic, agreed, noting that the FOCUS Practice Improvement Module has seen a 50 percent reduction in the inappropriate rate from 10 percent to 5 percent, within 53 centers. Similarly, Gibbons noted that when comparing the appropriateness of procedures in the 2009 cardiac radionuclide imaging update to the original 2005 criteria, rates of inappropriateness had decreased, and the unclassified percentage was eliminated. "Time will tell and FOCUS will try," he said. "While the FOCUS effort is ongoing, its real-time clinical decision support offers promise."

Looking ahead, Allen Taylor, MD, FACC, chief of the Cardiology Division at Georgetown University Hospital, highlighted the need for AUC to be refreshed frequently in order to stay relevant and keep with the pace of rapidly changing technologies. He also noted that we can significantly influence practice to better align with AUC on a system level, but quality improvement initiatives at the local level are necessary to address gaps in individual practice improvement. Peter Tilkemeier, MD, FACC, also noted that referring physicians need to be educated about AUC. To do that, he said, there needs to be a varied approach for each constituency and each institution needs to be flexible. "Have the conversation, gather the data, get senior partner buy-in as well as a knowledge expert, and make sure there is goal alignment including financial incentives for all, and that the improved outcomes can be reached by working together and through transparent data sharing," he said.

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