Cath Lab Digest

Appropriate use criteria (often referred to as AUC) for various diagnostic tests and procedures are either already in place or being developed across the healthcare industry, with several professional organizations supporting their use. Cardiovascular procedures, including interventional radiology, echocardiography, and stress testing, as well as coronary revascularization, all currently have some guidelines in place for appropriate use with the backing of their respective professional organizations. Well-publicized inappropriate-stenting cases have focused regulatory and media attention on coronary stenting and have garnered support for the criteria use by providers, clinicians, and payors. While the underlying purpose of appropriate use criteria is the good intent to ensure that the right procedure is performed on the right patient at the right time for the right reasons, to achieve the best possible outcome, there are many organizations that struggle to ensure compliance with the criteria. Despite any one factor that makes total compliance somewhat of a struggle, Corazon believes it is always in the best interests of the organization from a clinical, regulatory, and financial perspective to work diligently towards achieving that compliance.

Background on criteria development

Appropriate use criteria for percutaneous coronary intervention (PCI) were developed by a technical panel of physicians who reviewed and scored approximately 180 clinical scenarios as to how likely it would be that revascularization would improve outcomes or survival of the patient. From that review, the determination was made whether the revascularization procedure had the appropriate indications and was medically necessary. Three relevant points to consider when using the criteria were stated in the ACCF/SCAI/AATS/AHA/ASNC 2009 Appropriateness Criteria for Revascularization¹:

• Appropriateness criteria are based on current understanding of the technical capabilities and potential benefits of the procedure;
• Future evidence development will require the criteria to be updated; 
• Appropriateness criteria are intended to assist patients and clinicians, but are NOT intended to replace clinical judgment and experience.

Thus, appropriate use criteria for PCI are a work in progress, as evidenced by the January publication of the 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update² that provides some clarification and additions to the original criteria. The 2012 update reassessed the clinical scenarios against new medical literature and worked to bridge gaps in the previous guidelines. As new information and technology emerges, the guidelines and criteria will require ongoing reassessment to ensure that evidenced-based care is the ultimate goal.

Categories of appropriate use

The AUC place procedures in one of three categories: (1) appropriate, (2) uncertain, or (3) inappropriate. What does placement of a case into one of these three categories mean for the patient, the medical practitioner, the cardiac catheterization laboratory, and the organization? The classifications are as follows:

• “Appropriate” is defined as a procedure that is generally acceptable and is a reasonable approach for the indication cited.
• “Uncertain” is considered generally acceptable and may be a reasonable approach. 
• “Inappropriate” means a case is performed for a procedure that is not generally acceptable and is not a reasonable approach for the indication that is documented. 

The most important issue to note here is that for each of these classifications, there is room to argue a case. That is, not all patient situations are the same, even with very similar coronary anatomy and/or disease. Other patient factors enter the picture and are as diverse as the human race. The classifications are a way to provide an overview of cases performed by a practitioner or an organization, and it is then up to that practitioner and the organization to explain (via documentation) why a case deemed uncertain or inappropriate may, indeed, be appropriate. A case identified as “uncertain” would need to have supportive documentation as to why a revascularization procedure was in fact the right thing to do for the patient, while any procedure that fails to meet the “appropriate” or “uncertain” classification should cause the practitioner to closely scrutinize the decision to perform the procedure. If, after review, the practitioner still feels the patient would have potential benefit from the procedure, it is crucial to scrupulously document all of the factors playing into that decision (be it diagnostic testing results, patient symptoms, patient co-morbidities, history, or any number of other factors).

This leads to a critical issue: documentation. While documentation is often a weakness for healthcare disciplines, the appropriate use criteria provide added motivation to complete supportive documentation for the procedure performed. While that is not to say you can just “talk your way into appropriateness,” it is possible to provide valid arguments, test results, and other indications that can provide convincing evidence that a particular patient may benefit from a procedure that may not be deemed as beneficial to the patient population as a whole. Appropriate use criteria essentially take a standard of care and apply it to the general population. All who work in healthcare realize there are patients and situations that call for an exception or deviation from a standard. Appropriate use criteria require the use of detailed documentation to justify that deviation.