Perspective:

This manuscript proposes a methodology to develop criteria to define appropriate utilization of cardiovascular imaging, in a manner that is jointly supported by the American College of Cardiology Foundation (ACCF) and the American College of Radiology (ACR). Seven key points to remember from this manuscript are:

1. While clinical treatment guidelines have been demonstrated to have a positive effect on patient outcomes, and have become an important measure of the quality of health care, appropriateness guidelines for the use of diagnostic imaging test present special challenges and are less robustly developed.

2. There is a need to merge the separate efforts of the ACR and ACCF in regards to appropriate use of cardiovascular imaging.

3. This manuscript proposes a methodology to develop appropriate use criteria for cardiac imaging. The proposed organization structure includes several groups: A) an oversight committee, which oversees study methodology, defines the scope of the documents to be examined, and helps to select committee members; B) the writing panel, which develops clinical indications and scenarios, and evaluates and describes current literature; C) the review panel, which performs critical review and helps refine the work of the writing panel; and D) the rating panel, which rates the appropriateness of each of the clinical indications.

4. Each clinical scenario is given a score between 1 and 9. Scenarios can be rated as ‘rarely appropriate’ (score 1-3), ‘maybe appropriate’ (score 4-6), or ‘appropriate’ (score 7-9).

5. The ‘maybe appropriate’ category indicates that the panel agreed that there was insufficient evidence regarding whether the imaging test was appropriate, or that available evidence was equivocal/conflicting, or that additional factors must be considered.

6. Appropriateness scores are initially assigned independently by rating panel members. De-identified scores are then discussed during mandatory in-person meetings. When needed, a second round of independent ratings is then performed, potentially followed by a third round of ratings and/or a conference call. When ≥60% of scores fall within the same category, this score is used as the final rating.

7. An oversight committee representative will serve as a moderator for the ratings panel; this person must be ‘unbiased’ and ‘free of significant relationships with industry.’ The document has no other specific requirements regarding potential relationships between other committee/panel members and industry.