What are appropriate use criteria?

For the explanation of appropriate use criteria (AUC), please see Chapter 65 .

What led to the development of appropriate use criteria?

AUC were developed in response to the marked increase in the performance of and expenditures on cardiac procedures, particularly cardiac imaging, over the past two decades. Medical diagnostic imaging experienced a cumulative growth of 85% between 2000 and 2009, including a near doubling in the volume of transthoracic echocardiography (TTE). ^, This exceeded the growth of any other physician service. ^, Although an aging population with an increasing burden of cardiovascular disease may justify some of this growth, the magnitude of this increase in utilization and expenditures raised questions from governmental and private payers about potential misuse and overuse of cardiac imaging procedures. ^,

As a result of this increased scrutiny, more recent utilization of cardiac imaging procedures, including echocardiography, has moderated. Between 2009 and 2011, the most recent time frame for which data are available, for the first time volume of all imaging services to Medicare beneficiaries declined (3.5%). Utilization of echocardiography procedures has been a similar path, declining 5.5% over the same time period ( Fig. 198.1 ).

Growth in volume of echocardiography procedures provided to Medicare enrollees per 1000 beneficiaries, 2000-2011. Note: Some services are billed as individual components of a comprehensive study.

(Data from Medicare Payment Advisory Commission [MedPAC]. 2013 Report to Congress: Medicare Payment Policy, March 2013, and Andrus BW et al. Circ Cardiovasc Qual Outcomes 5:31-36, 2012.)

Although the reasons for the reduction in utilization of echocardiography have not been definitively determined, contributors have been identified. Reimbursement cuts that took effect in January 2010 and implementation of utilization management efforts such as prior authorization processes have been examples of successful governmental and private-payer attempts to decrease utilization and contain costs. ^, The development of AUC has also played an important role, representing a physician directed effort to provide practitioners and reimbursement agencies “a rational approach to the use of diagnostic imaging in the delivery of high quality care.” To this end, the AUC have raised physician awareness and provided a vehicle to guide the optimal use of echocardiography in current clinical practice.

What do the appropriate use criteria for echocardiography tell us about current clinical practice?

Since publication of the AUC for echocardiography, a large of number of clinical implementation studies have provided a description of the appropriateness of the current clinical practice of echocardiography in a variety of populations and practice settings. The following themes have emerged.

A large majority of echocardiography procedures performed are appropriate. For TTE, depending on population and practice setting, 71% to 92% of studies have been found to be ordered for “appropriate” indications. The most common appropriate indications for which TTE are ordered in clinical practice are listed in Box 198.1 . For transesophageal echocardiography (TEE), an even greater percentage of studies are ordered for “appropriate” indications (95%), likely because the invasive nature of TEE requires greater physician involvement and screening. ^, The AUC for stress echocardiography (SE) are discussed in another chapter in this book.

A wide range of rates of “inappropriate” (now termed “rarely appropriate”) TTE studies have been reported (2% to 22%), whereas “rarely appropriate” TEEs (3% to 4%) have been shown to be extremely rare. ^, The most common “rarely appropriate” indications for which TTEs are ordered in clinical practice are listed in Box 198.2 . “Rarely appropriate” echocardiographic studies have been the primary target of efforts to reduce utilization of echocardiographic procedures. Educational interventions aimed at orienting ordering clinicians to the AUC have been shown to be successful in reducing the number of inappropriate TTEs performed.

What can we learn from “inappropriate” (now termed “rarely appropriate”) studies?

There has been great interest in identifying characteristics of “rarely appropriate” studies that might be used to target efforts to reduce inappropriate utilization of echocardiography, constrain costs, and optimize clinical practice. Characteristics such as practice setting (community vs. academic) have not been shown to significantly affect appropriateness. ^, Physician ordering specialty (cardiologist vs. other) has been studied extensively, with mixed effects on the appropriateness of echo practice in different populations studied. ^{, ,} The two characteristics that have consistently been associated with more “rarely appropriate” TTEs are outpatient status and repeat studies. Outpatient TTEs are less appropriate than inpatient TTEs in large part because hospitalized patients are more likely to have new symptoms or a “change in clinical status,” which the key feature establishing many AUC indications as “appropriate.” ^{, ,} Similarly, repeat TTEs are less likely to be appropriate than first-time TTEs because indications in the AUC specify time intervals for reevaluation of heart disease in the absence of a clinical change; below these intervals, the repeat TTE would not be deemed appropriate (e.g., AUC indication 35: “Routine surveillance (< 3 years) of mild valvular heart disease without a change in clinical status or cardiac exam”). ^, Routine repeat TTEs are among the most common “rarely appropriate” indications for TTE in clinical practice and represent a primary target to optimize utilization.

How will the appropriate use criteria be implemented into clinical practice?

AUC were developed with the expectation that they will be implemented in the routine clinical practice of echocardiography. Over the past decade, cardiac imaging tests have increasingly been subjected to precertification or prior-authorization procedures before performance of individual imaging procedures. ^, These precertification procedures are generally performed by radiology benefit managers (RBMs) on behalf of third-party payers. ^, Although successful in limiting utilization, these processes have been unwieldy for physicians and patients as they may delay or deny necessary imaging tests. ^, The AUC have been put forth as an alternative to prior authorization. Electronic applications and software to be incorporated as part of order entry in electronic medical record systems have been developed and found to be feasible to employ in clinical practice. ^, Currently, the AUC for a variety of cardiac imaging modalities are being piloted as a potential replacement for, or to facilitate, prior authorization procedures in a number of locations across the country.

AUC reporting is also now a requirement for imaging laboratory accreditation for all cardiac imaging modalities, including echocardiography. The Intersocietal Commission for Accreditation of Echocardiography Laboratories (ICAEL) currently requires that the AUC be applied to 30 consecutive TTEs, TEEs, and SEs annually, with laboratory appropriateness rates included in annual quality improvement documentation. In addition, laboratories must have a “mechanism for educating referring physicians to improve appropriate use.”