Editorial

The Role of Appropriate Use Criteria forCoronary Revascularization

W. Douglas Weaver,1 MD, FACC, FAHA, Timothy J. Gardner,2 MD, FACC, FAHA,and Joseph D. Babb,3 MD, FACC, FSCAI

In this week’s Journal appears the first ACC Appro-priate Use Criteria* (AUC) for coronary revasculariza-tion. Since 2005, the College has published AUC forseveral cardiac imaging methods. Because AUC arepublished alongside clinical practice guidelines andperformance measures, it may now be necessary todefine how AUC serve a distinct purpose and providecomplementary information to other ACC clinicaldocuments. AUC are developed to determine whethera particular approach to care is reasonable in a givenclinical scenario. This is partly in response to a grow-ing concern from payers and patients regarding thepotential overuse or misuse of advanced technologiesfor cardiovascular care. Most Practice Guideline docu-ments provide a comprehensive summary of evidence-based care surrounding a particular cardiovascular con-dition or occasionally a specific procedure, such aspercutaneous coronary intervention (PCI). Extensivereview and analysis of the evidence from randomizedclinical trials and other published studies are under-taken to develop Practice Guidelines. In areas in whichthe evidence is insufficient, expert consensus is used toformulate recommendations for care. The PracticeGuidelines are then reviewed, revised, and vetted byboth internal and external physician reviewers, andthen finally by both the Board of Trustees of the ACCand the Scientific Advisory and Coordinating Commit-tee (SACC) of the American Heart Association beforethey are officially endorsed and published.In many areas however, such as cardiac imaging,

there is little or no outcome data or there are only

small and typically non-randomized published trials,and thus a comprehensive evidence-based Guidelinedocument is not feasible. The data, then, that is usedare often incomplete and were obtained from a limitednumber of subjects. In some areas of Practice Guide-lines, the level of evidence is reduced to group consen-sus due to the lack of ‘‘hard’’ data from randomizedcontrolled trials. The same holds true for cardiac cath-eterization and coronary revascularization when onetries to extrapolate and apply study findings to realworld scenarios. For this reason, there is substantialvariation in the application of these procedures. Wenn-berg’s Dartmouth Atlas graphically depicts wide geo-graphic differences in the use of cardiovascular testingand revascularization procedures [1]. The presence ofsuch marked variation raises questions of overuse,underuse, and even abuse of cardiovascular procedures.Overuse of procedures may potentially represent themisalignment of incentives in the delivery of care, orpractice patterns that do not reflect good stewardshipand value for our financially stressed healthcare sys-tem. Underuse of procedures may represent eitherinequities of healthcare delivery due to ethnic, gender,or socioeconomic factors, or inappropriate overuse inother circumstances. The College has elected to con-front this issue of wide variation in procedure utiliza-tion by establishing Appropriate Use Criteria. Thegoal of AUC is to define what is considered reasonablecare or possibly inappropriate care for specific clinical

1President of the American College of Cardiology2President of the American Heart Association3Past-President of the Society for Cardiovascular Angiographyand Interventions

Received 27 January 2009; Revision accepted 27 January 2009

DOI 10.1002/ccd.22025

Published online 12 February 2009 in Wiley InterScience (www.

interscience.wiley.com).

*Given the growing interest in appropriateness criteria from law-

makers, the media, payers and others, future criteria will be called

‘‘Appropriate Use Criteria’’ to better reflect the important role the

criteria play in identifying the appropriate use of medical technol-

ogy and procedures. The Coronary Revascularization document

has maintained the former title, because it was mainly developed

during the period when these documents were named Appropriate-

ness Criteria.

' 2009 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 73:439–440 (2009)

indications. Coronary revascularization is deemedappropriate when the expected benefits, in terms ofsurvival or health outcomes (symptoms, functional sta-tus, and/or quality of life) exceed the expected nega-tive consequences of the procedure [2].AUC methodology is quite different from that of

Practice Guidelines, and is detailed in the preface ofthis month’s publication. It can be summarized as fol-lows: First, a multi-specialty writing group generates alist of clinical scenarios and the evidence base. In thecase of coronary revascularization, there were 180 dif-ferent scenarios. Second, a review panel of about 30content experts critiques the efforts of the writing group.Third, a technical panel, composed of ‘‘experts’’ in thetechnology or procedure being evaluated, generalists,the ‘‘users,’’ and insurers, representing the ‘‘payers,’’is established. The technical panel is provided summa-ries of the available evidence as well as any of the rel-evant Practice Guidelines recommendations to helpguide in their rankings. The scenarios are then ratedindividually by each technical panel member. The rat-ings reflect not only the potential benefit and harm tothe patient, but also are made with an understanding ofresource use and costs, ‘‘intuitive cost-effectiveness,’’with reasonable care considered as the standard. Thetechnical panel then convenes for a face-to-face meet-ing where members can exchange views on their indi-vidual ratings. The goal of the process is not to reachconsensus, but rather to provide a full discussion priorto the final rating. Following the face-to-face meeting,the technical panel rates the scenarios for the secondand final time.The accompanying AUC document developed a

framework for evaluating the strategy of coronary re-vascularization through the analysis of the followingclinical features:

1. Symptom status of the patient2. The adequacy of the medical management of angina3. The ischemic burden as determined by non-invasive

testing4. The patient’s coronary anatomy

These features provide clinicians and patients a wayof discussing the relative merits of revascularization.There are certainly other potential factors in revascu-larization decisions, but these four were consideredcritical for the majority of the cases. The interrelation-ship of appropriate (A), uncertain (U), and inappropri-ate (I) designations through the mapping of patientsymptoms versus stress imaging findings versus coro-

nary anatomy versus medical treatment intensity pro-vides a excellent and reliable ‘‘patient-centric’’ toolfor Practice Guidance [3].With the recent development of AUC, it is now pos-

sible to measure individual practice patterns and thenmake comparisons through benchmarking to one’speers. If you don’t measure performance, how can youever improve it? The goal of all of this is to helpguide more effective care that ultimately improvespatient outcomes and improves the value of care deliv-ered by increasing efficiency. Ultimately, the goal is toembed these criteria into order entry systems and otherelectronic point-of-care decision aids to provide ‘‘justin time’’ information for the practicing physician.Many of our documents address diagnostic proceduresthat are ordered by a wide variety of generalists andspecialists, few of whom will ever be familiar with thenuances of appropriate use, and will now have expertderived information and feedback to guide them intheir care plans for patients.In summary, AUC can complement Practice Guide-

lines by providing an outline of reasonable care formany common clinical situations that can not beadequately addressed otherwise. In this current effort,we attempted to cross-tab those scenarios where rec-ommendations existed in the Practice Guidelines. Wefound 100% congruence between the Class I and IIIrecommendations and AUC ratings, despite goingthrough two very different procedures to get there.In the foreseeable future, our AUC will be able to

offer almost ‘real time’ updated ratings and recommen-dations as new clinical evidence becomes availableand we have in place electronic aides to augment and‘‘supercharge’’ AUC implementation. Our currentpractice style is too variable and too expensive for thevalue presently being derived. These standardizedapproaches are one way to provide more consistentcare and more efficient care in order to do the rightthing the first time.

REFERENCES

1. The Dartmouth Atlas of Health Care. The Dartmouth Institute.http://cecsweb.dartmouth.edu/atlas08/datatools/dgraph_s1.php.

2. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA.

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness crite-

ria for coronary revascularization. J Am Coll Cardiol 2009;53:

xxx–xx.

3. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA.

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness crite-

ria for coronary revascularization. J Am Coll Cardiol 2009;53:

xxx–xx.

440 Weaver et al.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).