This post is authored by Ralph G. Brindis, MD, MPH, MACC, Immediate Past President of the American College of Cardiology
In medicine there are cases in which most physicians could decide instantaneously which procedure would be best for the individual patient, and there are times when physicians are on the fence and turn to the clinical practice guidelines to help guide their decision. The ACC and AHA have been working together to create these clinical guidelines for over 25 years. The guidelines provide a foundation for summarizing evidence-based cardiovascular care, and where there is evidence lacking provide expert consensus opinion. However, variability still remains raising the question of over- or underuse.
The Appropriate Use Criteria (AUC) are decision support quality improvement tools that are intended to help clinicians select the right patients for the right diagnostic tests, and provide a practical standard upon which to assess and better understand variability. However, as with any system, there is room for improvement and in the case of the AUC, there are times when what’s best for an individual patient isn’t always deemed appropriate and what is deemed appropriate isn’t always best for the individual patient.
As the field of medicine rapidly changes, it remains a challenge to stay current with the new and evolving science. Over the years the ACC has seen a need for true “living documents” that respond rapidly to the changing evidence created from random clinical trials or even from the College’s National Cardiovascular Data Registry (NCDR). Fortunately under Alice Jacobs’, MD, FACC, Chair of the ACCF/AHA Task Force direction, clinical guidelines have become more timely through focused updates and are more congruent between related guidelines to minimize the risk of discordant recommendations between guidelines simply due to the timing of the updated cycle. The 2012 AUC coronary revascularization update reflects such changing science learned from the SYNTAX trial in addition to assessing other clinical scenarios not originally evaluated in the first 2009 AUC document.
Many concerns and questions still remain about AUC – relationships with clinical outcomes in their application, negative unintended consequences, and so forth. Several interesting editorials have recently been published including, “The Privilege of Self-Regulation – the Role of Appropriate Use Criteria” and “Percutaneous Coronary Intervention Use in the United States: Defining Measures of Appropriateness.” These papers offer food for thought as we move forward implementing new science and technologies.
Important ongoing studies are also now assessing the application of AUC with looking at midterm CV clinical outcomes while closely assessing for the potential for negative unintended consequences. Professional societies such as the ACC need not only to educate our members as to the value of AUC implementation in their practice but perhaps even more importantly need to aggressively educate our patients, the media, and payers and purchasers as to the proper use and caution for misuse of AUC assessments.
The AUC task force is continuously faced with new challenges, but the cardiovascular community is privileged to be able to measure ourselves against one another as we strive for the best outcomes for our patients.
I invite you to share your thoughts about AUC and the way they are evolving with new science in the comments section below.