Appropriate Use Criteria

Appropriate Use Criteria in the Cath Lab: Can We Make Implementation Easier?

Kishore J. Harjai, MD, MMM, FACC, FSCAI(1), and Sudhakar Sattur, MD, MHSA(2)
Kishore J. Harjai, MD, MMM, FACC, FSCAI(1), and Sudhakar Sattur, MD, MHSA(2)

1. Medical Director, Structural Heart Intervention, Geisinger Clinic (Northeast), Wilkes-Barre, Pennsylvania; 2. Fellow, Interventional Cardiology, The Methodist Hospital, Queens, New York. 

Disclosure: Drs. Harjai and Sattur report that they are co-founders of aucportal.org.   Dr. Harjai can be contacted at harjai@aucportal.org.

Cardiovascular disease is the leading cause of death in the United States and cardiovascular services consume a significant proportion of the total healthcare dollar. According to estimates by the American Heart Association, the direct cost of cardiovascular care will triple from 2010 to 2030. There is significant disparity in the utilization of cardiovascular services within different regions of the U.S., which cannot be explained by differences in overall quality of care. Reimbursement to hospitals and health care providers is based on volume of services provided. These factors have led to the perception that some cardiovascular procedures performed in the U.S. may not be absolutely necessary. In the recent past, the “value” of health care services was defined as quality divided by cost.  In the era of cost-consciousness, value is increasingly defined as (Appropriateness x Quality) / Cost (Figure 1).  

The American College of Cardiology Foundation, in conjunction with several key professional societies, has spearheaded the development of Appropriate Use Criteria (AUC) for several cardiovascular procedures: cardiac magnetic resonance imaging1, nuclear stress testing2, cardiac computerized tomography3, echocardiography4, cardiac catheterization5, coronary revascularization6,7, peripheral vascular ultrasound and physiologic testing8 and implantable cardiac defibrillators/cardiac resynchronization therapy9. The purpose of the AUC is to promote the rational use of cardiovascular procedures in the delivery of high-quality care.

In formulating the AUC, indications for each cardiovascular test were developed by a writing panel and rated by a separate expert panel on a scale of 1-9. Thus, the need to perform a test in a given clinical scenario is rated by the experts as ‘appropriate’ (median score 7-9), ‘may be appropriate’ (median score 4-6) or ‘rarely appropriate’ (median score 1-3). Multiple clinical scenarios have been described in each of these documents, representing a plethora of useful information. Unfortunately, the practical use of AUC is limited by several logistic factors. There are hundreds of specific scenarios, making it difficult for the clinician to find a specific scenario or accurately reproduce the appropriateness rating in a busy clinical setting. The evidence supporting these ratings is not cited in the AUC documents, limiting the clinician’s ability to review original research. Incorporation of AUC ratings in paper or electronic medical records is cumbersome. Further, there isn’t an open forum for healthcare personnel to debate the AUC ratings. To overcome these limitations, we have developed a host of tools called aucmonkey.com, available as a website, and iOS and Android apps. Collectively, aucmonkey.com represents a set of informational and efficiency tools designed to help healthcare personnel make informed decisions, document necessity of cardiovascular investigations, assure quality of care, and ensure that they get paid fairly for cardiovascular tests. Some screen shots and available features are depicted in Figures 2-7. Registration and initial use of aucmonkey.com for 2 months is complementary. We believe that the regular use of aucmonkey.com will help physicians, nurses, and technologists optimally utilize AUC in many settings, such as clinical practice, research, quality assurance within large groups, and for educational purposes. The algorithms relating to diagnostic catheterization, revascularization, and electrophysiology are particularly useful for cath lab-based personnel.

The expected implementation of Obamacare and the emphasis on cost containment will lead to a surge in the use of AUC in cardiovascular medicine and other fields. A recent study from the American College of Cardiology-National Cardiovascular Data Registry sparked a huge debate by implying that about 50% of all percutaneous coronary interventions performed in the U.S. in patients with stable coronary disease were not appropriate.10 Although somewhat sensationalistic, this study acutely raised awareness about AUC among clinicians, health care payers, educational institutions, quality assurance personnel, and patients alike. It is our belief that AUC will continue to evolve and become the de facto standard of care for cardiovascular medicine.  

In daily clinical practice, disparities continue to exist between what clinicians and payors deem to be necessary. This often leads to rejections of payment for services or lengthy pre-authorization processes that are a burden for the clinician’s office staff. Further, quality assurance departments in many practices and hospitals have begun to address not only the quality of procedures performed, but also the value that testing or treatment brings to the individual patient. Eventually, the AUC could become the common language spoken by clinicians, payors, quality assurance personnel, and educators alike. 

References

  1. American College of Radiology; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; American Society of Nuclear Cardiology; North American Society for Cardiac Imaging; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging. A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group. J Am Coll Radiol. 2006 Oct; 3(10): 751-771.
  2. Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009 Jun 9; 119(22): e561-e587. doi: 10.1161/CIRCULATIONAHA.109.192519. 
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