Back to the Basics – History of the AUC

This post was authored by Michael Wolk, MD, MACC, past president of the ACC.

We’ve come a long way over the past eight years with the development of Appropriate Use Criteria (AUC). To understand why these criteria are important to our daily practice, we must remember why the concept was first developed. More than a decade ago, usage statistics for diagnostic imaging was shown to have the fastest growth among all medical services covered by Medicare. At the same time, health plans in California were starting to review and question PCI and CABG cases based on RAND appropriateness criteria developed during the 1990s. The ACC’s Medical Directors’ Institute, as well as leaders from our Board of Governors, saw this as both a challenge and an opportunity to look at both over- and under- use of procedures.

Upon approval by the Board of Trustees, we accepted the challenge of providing guidance regarding appropriate use of cardiovascular procedures, and ran with it. We created an Appropriateness Criteria Working Group involving several ACC leaders and published the document, ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging. Soon after, in October 2005, the first AUC document was published for SPECT MPI, ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). Upon completion, we held a summit to receive feedback on the process and how it might be improved. This information was used to refine the process including introducing early review of proposed clinical scenarios, larger expert panels, more comprehensive lists of clinical scenarios and ongoing coordination with clinical guidelines and other ACC policy documents. To date, the ACC has developed AUC for echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, cardiac radionuclide imaging, coronary revascularization and diagnostic catheterization. Currently under development are documents on implantable defibrillators and cardiac resynchronization, peripheral arterial and venous ultrasound, ultrasound use in pediatric patients, and multi-modality imaging use in heart failure, chest pain, and stable ischemic heart disease.

AUC define “when to do” and “how often to do” a given procedure in the context of scientific evidence, the health care environment, the patient’s profile and a physician’s judgment. The criteria can help inform individual patient care decisions but are best used to evaluate patterns of care by physicians over time.  All of the criteria are developed by panels of clinical experts from the ACC Foundation and its partner organizations based on evidence and when necessary expert opinion. The panels assess the benefits and risks of a procedure for different indications or patient scenarios and then determine whether the indication is appropriate, uncertain, or inappropriate. It is important to note that AUC ratings often contain more detailed scenarios than the recommendations covered in practice guidelines and thus subtle differences are possible. The criteria are also based on current understandings of technical capabilities and potential patient benefits of the procedures examined, and future evidence development will require these ratings to be updated on a regular basis.  In general, the documents have been updated every one to two years with all except the CMR AUC having been revised at least once since their original ratings.

I wrote in a 2004 President’s Page that “some may not see the importance of the College’s efforts to address appropriateness. Some might argue that explicit guideline performance indicators can be divisive and prefer we not enter this arena. However, if we do not lead in this effort, others may set criteria that may not be wise either for us as physicians or for our patients.”

Eight years later, I believe the same scenario rings true. (Although looking at today’s use of radiology benefit management companies, I would change the last part of the sentence to “others WILL set criteria …”) It is our duty as a profession to work together with policymakers, payers and other medical societies to ensure patients are receiving the most appropriate care, while also reducing unnecessary health care costs and limiting wide variations in care delivery. This is about “doing the right thing” and is best done by our own standards based on the latest science.

For more information about AUC visit

This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.

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