By Steven R. Bailey, MD, FACC; John U. Doherty, MD, FACC; Christopher M. Kramer, MD, FACC; Michael J. Wolk, MD, MACC; Joe Allen, MS; Jenissa Haidari, MPH
The development of ACCF Appropriate Use Criteria (AUC) began in 2005, with the goal of engaging with cardiovascular professionals to be stewards of medical resources in ways that could provide value-added care and preserve physician/patient decision making1. These documents sought to define when and how often to do an imaging test or procedure for populations of patients rather than on a case-by-case basis and were developed for a wide range of applications, including detection or exclusion of disease, risk stratification and evaluation of therapeutic benefit.
However, adoption of AUC by clinicians has been slow largely due to several key misunderstandings about AUC including: 1) the methodology for AUC construction, 2) the application of AUC to clinical care, and 3) the category labels of “uncertain” and “inappropriate.” In an effort to address these issues, the ACC’s AUC Task Force recently conducted a survey of 975 health care professionals, the majority of whom were ACC members, to help gauge current knowledge, use, and potential avenues for improving the understanding-clarity and utilization of AUC.
Overall the survey results showed that the majority of health care providers view improved care delivery, education and cost reduction as the primary benefits of AUC.
The most often identified benefit, by 54% of participants, was to improve decision making by practitioners in day-to-day clinical care. Participants also responded to questions on how to improve AUC use, with the most common responses endorsing increased education and quality improvement programs to improve physician understanding and use of AUC criteria, as well as reporting of AUC compliance across physician groups and/or across a practice over time. Reporting of compliance across patient groups was also noted as useful, however, only 9% preferred per patient case alone as a method of identifying compliance.
The vast majority of participants (92%) felt that professional discretion is intrinsic to clinical decision-making and that AUC are not a substitute for clinical judgment. The preponderance of those surveyed (93%) also felt that the “uncertain” category should be reimbursed all or some of the time, with about 50% incorrectly assuming that an “appropriate” study must be performed most of the time. The intent of the AUC is to allow for clinical judgment across all categories and determine the frequency for which the procedure may be an option, not a requirement for good care.
Prior notification and prior authorization were not viewed as useful methods for improving adoption of AUC, with 46% of those surveyed suggesting that health plan utilization reviews are not consistent with AUC. Almost two thirds (63%) thought that health plan utilization management policies should be altered to be consistent with AUC.
Finally, survey participants expressed significant dissatisfaction with the original AUC rating methodology of ”appropriate,” “uncertain,” and “inappropriate.” Almost two-thirds of professionals felt that one or more of the terms should be changed, especially “inappropriate” (41%) and “uncertain” (35%). These recommendations for change were grounded in concerns over how the AUC criteria would be applied with respect to the care for individual patients and the potential for misunderstanding about the ethical and legal implication of the current terms.
When asked about the ACC’s new terminology, “may be appropriate” was the highest rated alternative to “uncertain” with remarkable consistency throughout the groups. Survey respondents felt the new terminology better reflected the fact that there may be cases in which the suggested management from an individual case scenario might be considered.
The community indicated that if the care was labeled as uncertain that it could be misconstrued as unnecessary or should not be performed rather than reflecting a variation in practice or patients. Similarly, the term “rarely appropriate” was the most frequent suggestion to replace “inappropriate” and was felt to convey the sense that, after due consideration of individual patient features, a physician may infrequently choose to suggest the procedure in question.
Moving forward, it is clear that most ACC members and health care stakeholders agree with AUC goals. However, there is room for improvement in the understanding of AUC methodologies in certain areas. The new AUC terminology released this past February will hopefully lead to increased use of AUC moving forward.
- Douglas PS, Wolk MJ, Brindis R, et al. President’s Page: appropriateness criteria: breaking new ground. J Am Coll Cardiol. 2005; 26:2143-4.