Appropriate use criteria (AUC) are designed to help make sure that medical procedures and interventions are performed in people most likely to benefit and, in turn, are not performed in people unlikely to gain benefit. Now a new study published in Annals of Internal Medicine suggests that the AUC for one very widely performed procedure, diagnostic cardiac catheterization, can provide a very rough indication of when it should and should not be performed, but that a great deal more work needs to be done before the criteria can be considered broadly reliable.
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A new study finds that groups who have often been found to receive less medical care– non-whites, women, and people without private insurance or who are from urban and rural areas– are less likely to undergo coronary revascularization. But the same study finds that this disparity may be in no small part due to the fact that these same groups are less likely to receive inappropriate procedures. The study, published online in the Journal of the American College of Cardiology, suggests, therefore, that the apparent underuse of healthcare in some groups may be partly counterbalanced by overuse in other groups.
In an interview with CardioExchange, Chan said that although “we have come a long way in ensuring that care is delivered equitably and thoughtfully in the US… there is no doubt that underuse in certain populations remains a persistent and huge problem. For policymakers… it highlights the importance of thinking about differences in treatment in a more complex way– as due to underuse and also potential overuse. Therefore, the goal may be to narrow the gap in vulnerable populations in instances where treatment has clearly established benefit rather than assuming that the measured difference is entirely due to a disparity in care.” Chan also said the paper was consistent with the hypothesis that patients for whom physicians are paid more are more likely to undergo inappropriate procedures.
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The American College of Cardiology (ACC) has published appropriate use criteria (AUC) for peripheral vascular ultrasound and physiological testing. The criteria were developed in coordination with 10 other medical societies.
“This is the first systematic and comprehensive evaluation looking at appropriate indications for vascular testing, such as ultrasound or functional testing,” said Emile Mohler III, the chair of the writing committee, in an ACC press release. “We hope this document will help clinicians determine whether or not and when to refer individual patients for testing.”
The 19 members of the panel identified common clinical situations in which noninvasive vascular testing is often considered and then assessed the appropriateness of each indication. In half of the scenarios testing was deemed to be appropriate. In general, tests were considered appropriate when they were prompted by clinical signs and symptoms.
About 20% of scenarios were judged inappropriate. Here are examples cited by the ACC in the press release:
- Ordering an ultrasound of the carotids or neck arteries in someone at low risk for heart attack or stroke.
- Screening for kidney artery disease in someone with peripheral artery disease with well controlled high blood pressure (hypertension) on one medication
- Choosing to perform an abdominal ultrasound in a patient with non-specific lower extremity discomfort
- Ordering a mesenteric artery ultrasound (arteries that supply the small and large intestines) as an initial test to evaluate the patient with chronic constipation or diarrhea
- Performing a follow-up study for a patient with a normal baseline study who has no new symptoms
Click here to read the press release from the ACC…
A large study looking at real world usage of elective coronary artery bypass surgery (CABG) and stenting (PCI) in New York State finds that nearly two-thirds of PCI procedures have inappropriate or uncertain indications. By contrast, 90% of CABG procedures were deemed appropriate and 1.1% inappropriate.
In a paper published in the Journal of the American College of Cardiology, Edward Hannan and colleagues analyzed data from NY State patients who received CABG or PCI in 2009 and 2010 and applied appropriate use criteria (AUC) from the ACC, the AHA, and other organizations. (The study only included patients without an acute coronary syndrome (ACS) or previous CABG, as these indications have not generally been the subject of previous concern. By contrast, a large, controversial study last year, that found a significant percentage of nonacute PCIs were performed for inappropriate or uncertain indications, included patients both with and without ACS.)
Here are the main findings of the study:
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For more than a year now the federal investigation of hospitals suspected of improperly implanting ICDs has been the subject of considerable rumor and speculation. Now, two cardiologists who were involved in a federal audit at one hospital have published a detailed account of their experience.
Jonathan Steinberg and Suneet Mittal are Columbia University-affiliated electrophysiologists who also direct the EP program at a large suburban nonteaching hospital. In a special article published in the Journal of the American College of Cardiology, the two authors describe the audit process and subsequent events in the hope that their experience “might provide valuable lessons” to others involved in similar cases.
The initial government analysis had found that 229 cases, representing 8.7% of all de novo ICD implants for primary prevention between 2003 and 2010, did not warrant coverage. Following a more detailed review of the medical records, the authors report that a much smaller number of cases, 34, representing 1.3% of all implants, were truly not indicated. These cases mostly occurred after bypass surgery in the setting of non sustained VT and/or a positive EP study, according to the authors. By contrast, a small number of cases had a clear secondary prevention indication, but the records for the earlier cardiac arrest or VT event were at another hospital.
Most of the cases were somewhat more ambiguous. Steinberg and Mittal list five common types of cases which were difficult to categorize and which “highlighted the complexity of adjudicating between clinical practice and the contemporary regulatory environment.”
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A group of leading interventional cardiologists has launched an attack on the growing role of appropriate use criteria (AUC) for PCI in the US. They argue that severe flaws in current guidelines render unreliable current attempts to assess the rate of appropriate procedures.
In a paper published in JACC: Cardiovascular Interventions, Steven Marso and colleagues (Paul Teirstein, Dean Kereiakes, Jeffrey Moses, John Lasala, and J Aaron Grantham) criticize a study in JAMA published last year from the National Cardiovascular Data Registry (NCDR) that found a large degree of inappropriate or uncertain PCI procedures, as well as a wide range of variability among institutions. Marso et al write that the JAMA paper sensationalized the data by focusing attention on the low rate of appropriate indications for nonacute PCI– 50.4%– while failing to point out that the study found that 84.6% of procedures in the entire study population– acute and nonacute alike– were deemed appropriate. Furthermore, given the imprecision built into the system, they ask: what is the “acceptable threshold” of inappropriate PCI?
The authors write that the AUC panel “purposefully limited involvement of the interventional community during the development process, in order to avoid having a majority of committee members “whose livelihood is tied to the technology under study.” But the under-representation of interventionists may have biased the results, they argue. One particular case as graded by the AUC panel was the most common reason for cases to be categorized as inappropriate: the AUC committee decided that PCI was inappropriate for a patient with 1- to 2-vessel disease, no proximal LAD involvement or prior CABG, class I or II symptoms, low-risk noninvasive findings, and on no or minimal medications. But most clinicians believe this is an uncertain but not inappropriate indication, they say. The AUC panel may have “got this one wrong,” they write.
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The ACC, AHA, and other organizations have released updated appropriate use criterial for coronary revascularization. The 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update incorporates data from the SYNTAX trial on the indications for PCI and CABG in patients with symptomatic, multivessel disease, as well as data from the CathPCI registry.
Here are some of the key ratings:
- PCI for low burden left main disease alone or with blockages in other arteries with a low disease burden: uncertain
- PCI for intermediate or high burden left main disease: inappropriate
- PCI for low burden three-vessel disease: appropriate
- PCI for intermediate or high burden three-vessel disease: uncertain
- CABG remains appropriate for patients with two vessel disease including the proximal LAD and all three vessel and left main disease.
Click here to read the press release from the ACC, AATS, and SCAI…