Use of Appropriate Use Criteria Is Increasing, but What Are Their Effects on Medical Care?

Abstract

Editorial 4T he first appropriate use criteria (AUC) for coronary revascularization were published in 2009 with an update published in 2012.1,2 A new version of the AUC for coronary revascularization is currently under development and will, we hope, address some of the constructive criticisms directed at the earlier versions. The use of AUC is increasing, and several other organizations have developed AUC for different procedures outside the cardiovascular arena. For example, orthopedic surgeons now have AUC for several of their common procedures, the American Academy of Dermatology has AUC for Mohs surgery, and AUC for the placement of Foley catheters recently were published. [3][4][5] With the increasing development, promotion, and adoption of AUC, it is reasonable to ask a critical question: What are the effects of AUC on the delivery of cardiovascular care? This is a fair question because the AUC are intended to address the rational use of coronary revascularization, to provide a practical standard on which to assess and understand variability, and to evaluate overall patterns of care for coronary revascularization. Article see p 20The article by Bradley and colleagues 6 in this issue of Circulation provides some insight into that question. Using data from the Washington State Clinical Outcomes Assessment Program, they examined temporal trends in the number of percutaneous coronary intervention (PCI) procedures performed, specifically the number of PCIs rated as inappropriate. High-performing hospitals were identified by a low or declining proportion of inappropriate PCIs or PCIs performed with insufficient preprocedural information to allow the assessment of appropriateness. They showed that, after the adoption of the Clinical Outcomes Assessment Program, there was an overall decline in the number of PCIs performed and specifically a substantial decline in the number of PCIs for elective indications. Although there was a slight increase in the number of PCIs performed for unstable angina or non-STsegment-elevation myocardial infarction during the same period, this increase was insufficient to explain the decline in elective PCIs. Therefore, the increase in PCIs for acute coronary syndromes was not felt to be the result of operators simply learning the coding system and shifting the diagnosis. The decline in the use of elective PCI was significantly larger after the onset of the statewide PCI appropriateness assessment, with a modest increase in the proportion of elective PCIs classified as appropriate and a modest decrease in the proportion of inappropriate PCIs. Of note, the decline in the proportion of inappropriate PCI was limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013). This observation must be viewed within the context that the number of PCIs in the United States has also declined in the same time period. Whether this is related to the overall adoption of the AUC for revascularization, AUC for diagnostic cardiac catheterizati...

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