In the last 10 to 15 years, technological advances have completely changed the way we deliver patient care on a daily basis. For cardiology in particular, noninvasive imaging is now central to clinical practice and research, irrespective of the disease entity or the area of interest of the cardiologist. Despite its unquestionable benefits, and because of earlier trends of increased utilization, medical imaging has been an area of focus by policymakers at the state and national level, as well as private payers; attempting to control who can perform imaging tests and where, through administrative protocols or state and federal laws as a means of reducing health care costs.

In my newest President’s Page in the Journal of the American College of Cardiology, I take a closer look at the past, present and future of cardiovascular imaging.  In particular I focus on what I consider to be a new imperative for medical imaging in light of the trend towards a more value-driven health care system and the fact that technology will continue to improve, enhancing our ability to diagnose and treat patients earlier. Novel technologies need to show a positive effect in patient care and outcome since ultimately, our driving concern is to achieve the triple aim of quality care, reasonable cost, and the health of the population.

The ACC has developed several tools to address over- and under-use of procedures and technologies and is widely credited by payers, members of Congress, and other stakeholders for working to address a perceived problem and taking proactive efforts to ensure quality, cost-effective care.

Notably, appropriate use criteria (AUC) define when and how often it is reasonable to perform a given procedure or test. When systematically implemented, AUC can be used to assess patterns of care in an effort to understand and improve the rate of clinically appropriate imaging tests, while reducing clinically less appropriate tests. By providing physicians with their imaging utilization, use of AUC also encourages the providers in shared responsibility for judicious use of imaging services and can effect appropriate change in behavior better than that observed with changing reimbursement.

Further, the College’s “Imaging in FOCUS” (FOCUS) tool, a self-directed, quality improvement software and interactive community was developed to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. It has proven successful in reducing overuse of imaging. Unlike Radiology Benefit Managers (RBMs) which have been criticized by health care providers for delaying or denying unnecessary administrative burdens, basing decisions on inconsistent rules and practices and lacking clinical guideline transparency, FOCUS is transparent, grounded in AUC, and provides opportunities, and in some cases, incentives, for improved AUC adherence.

Along the line of appropriate use, this past spring the ACC released a list of “Five things Physicians and Patients Should Question” as part of the Choosing Wisely campaign, led by the ABIM Foundation with eight other medical specialty societies. The list identifies five targeted, evidence-based recommendations that can support physicians and patients in making wise choices about their care. Three of the five recommendations were imaging related:

• Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
• Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
• Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.

As we continue to work towards implementing quality tools and efforts to address over- and under-use of procedures, I am proud of the College and its members for being at the forefront of this continuously developing field and working to make sure that patients reap the benefits of advances in imaging technology in a transparent, evidence-based manner.