American College of Cardiology Updates Appropriate Use Criteria Methodology

The American College of Cardiology (ACC) has released changes to the process for developing appropriate use criteria (AUC), including changes to frequently misinterpreted terminology for describing the levels of appropriateness of care.

Under the updated methodology, published on Feb. 21 in the Journal of the American College of Cardiology, appropriateness of procedures or use of imaging for specific populations will be described as "appropriate," "may be appropriate," or "rarely appropriate."

"The new terminology and definitions more accurately reflect how AUC should be used for quality improvement and clinically, including consideration for physician judgment, measurement of patterns of use over time and the potential hazard of applying inflexible rules to individual patient situations," said AUC Writing Committee Chair and lead author Robert C. Hendel, MD, FACC. "The new terminology will be applied in development of all subsequent appropriate use criteria. The first document using the new terms is slated for release later this month, focusing on implantable cardiac defibrillators and cardiac resynchronization."

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The methodology paper documents updates the appropriate use criteria development process that was first established in 2005 based on the RAND Appropriateness Method — a method developed to provide guidance for when and how often medical procedures should be performed. The method combines a comprehensive revise of the medical literature and expert opinion regarding commonly encountered clinical scenarios.

In addition to the terminology and definitions, the methodology paper formalizes changes made to the process over the seven years it has been in use. Changes include the introduction of a formal review process prior to rating, administration of a survey of professional expertise for rating panel balance, and establishment of a relationships-with-industry policy that reflects the multi-stage process of appropriate use criteria. Appropriate use topics are now being broadened to cover multiple procedures at once for a specific disease or clinical presentation.  Future documents will more often rate all procedures that might be relevant to a patient’s condition.
Appropriate use criteria are developed by more than 50 professionals representing various stakeholders involving a multidisciplinary approach.  Scenarios are crafted based on practice experience, matched against clinical trials, reviewed by a wide range of experts and then graded for appropriateness.
To date, the ACC has used the methodology to develop AUC for echocardiography, cardiac radionuclide imaging, cardiac computed tomography, cardiac magnetic resonance imaging, peripheral arterial and venous ultrasound, diagnostic catheterization and coronary revascularization. AUC for implantable cardioverter defibrillators and cardiac resynchronization therapy is due out in late February and will be the first to use the methodology. 
"Implementation of the criteria can help inform quality improvement efforts, engage patients and physicians in shared decision-making, and support the evolution of population based care toward patient-centered decision support," ACC President William A. Zoghbi, MD, FACC said. "Through AUC, the college has been proactive in enhancing the delivery of high quality, cost-effective care based on the best available evidence."
"The College will continue to work with practices and researchers to document the impact of AUC on care and encourage their use as a part of comprehensive payment reform," Zoghbi added. "AUC help ensure the best information is available for clinical decision making and help support appropriate choices by physicians and patients, in the context of good clinical judgment and patient preferences."
New terminology and definitions:

  • Appropriate Care: An appropriate option for management of patients in this population due to benefits generally outweighing risks; effective option for individual care plans, although not always necessary, depending on physician judgment and patient-specific preferences (i.e., procedure is generally acceptable
    and is generally reasonable for the indication).
  • May Be Appropriate Care: At times an appropriate option for management of patients in this population due to variable evidence or agreement regarding the benefit/risk ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient based on additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).
  • Rarely Appropriate Care: Rarely an appropriate option for management of patients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).

"Appropriate Use of Cardiovascular Technology: 2013 Appropriate Use Criteria Methodology Update" was published online Feb. 20 and will appear in the March 26 print issue of JACC.

Keywords: Health Personnel, Tomography, X-Ray Computed, Referral and Consultation, Magnetic Resonance Imaging, Cardiac Resynchronization Therapy, Quality Improvement, Research Personnel, Catheterization, Patient Preference, United States, Defibrillators, Implantable, Echocardiography

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