Applying Appropriate Use Criteria to Reduce Costs

An interview with Rami Doukky, MD, MSc, division of cardiology, John H Stroger Jr Hospital of Cook County, Chicago, Illinois.

Your recent piece in the Annals of Internal Medicine focuses on appropriate use criteria for cardiac imaging. Can you tell me why there was a need to develop these criteria?

In the 1990s and the early 2000s, there was an unsustainable growth in the use of cardiac imaging procedures. The increase in use was at twice the rate of growth in other medical services, suggesting excess and perhaps unnecessary use.

How do appropriate use criteria help physicians and payers determine a course of action?

By guiding physicians into evidence-based or expert guided use of imaging study, physicians and payers are guided toward most effective use of these procedures and steered away from inappropriate uses.  

Can you describe the structure of the cardiac imaging appropriate use criteria?

Based on clinical scenario, symptoms, risk factors, and other available tests, the criteria would classify use in three categories:

•Appropriate—when there is a proven value

•May be appropriate—when the value is uncertain

•Rarely appropriate (inappropriate)—when value is limited or risk outweighs the benefit.  

 Has the development and implementation of the criteria produced positive outcomes?

The introduction of the criteria has coincided with decreased utilization and general acceptance in the medical community. It is unclear whether decreased use is the result of the criteria or increased scrutiny on the part of payers.

How can adherence to the criteria and delivery of the desired outcomes (reducing unnecessary utilization) be achieved?

By integrating the criteria seamlessly in our workflow and greater education of their applications and value.

Can you explain how the Protecting Access to Medicare Act (PAMA) will impact use of the cardiac imaging use criteria?

If the implementation of PAMA is disruptive to the care process, it is plausible that medical societies refrain from developing more appropriate use criteria in the future. It is also plausible that future criteria are simplified to ease their use.

Are there any barriers to adoption of criteria under the PAMA?

Limited integration of computer-based Clinical Decision-Support Mechanism (CDSM) in workflow and electronic medical records. Also, lack of clarity regarding implementation and reimbursement claim requirements.

Can you elaborate on the CMS-approved “provider-led entities,” which have developed applicable criteria?

There are 11 organizations that have developed CMS-approved appropriate use criteria. Among the most prominent organizations are the American College of Cardiology and the American College of Radiology.

Do you think mandatory use of appropriate use criteria could have any adverse effects or produce any unintended barriers to treatment?

Certainly, limiting referral to necessary testing in order to avoid the hassle. Also, implementation may lead primary physicians to increase referral to consultation to avoid the hassle of using a computer-based CDSM.

Can appropriate use criteria be applied to other areas of health care utilization where similar issues with overuse exist? If so, which areas?

Medicine is ever increasing in complexity and sophistication. New and expensive tests and procedures with potential for excessive or unnecessary use are introduced to every field of medicine all the time. There may be a role for appropriate use criteria in any commonly used procedure. However, excess or poor implementation of new regulations around appropriate use criteria may discourage professional societies from developing new
appropriate use criteria.