Appropriateness criteria are becoming increasingly important in US health care. Not only do they allow for improved patient care and health outcomes in a cost-effective manner; they also act as useful and practical guidelines for the treating physician. These criteria are becoming a benchmark against which insurers will reimburse noninvasive testing. Unlike cardiac ultrasound indications, for which separate appropriateness criteria exist, the indications for arterial vascular ultrasound of all major vessels in the body are much broader and there is an even greater need for appropriateness criteria for peripheral vascular testing.
The report “2012 Appropriate Use Criteria (AUC) for Peripheral Vascular Ultrasound and Physiological Testing Part I: Arterial Ultrasound and Physiological Testing” fills this need. The criteria were set forth by the ACC Foundation’s Appropriate Use Criteria Task Force in collaboration with ASE and other major societies.
The report evaluated a total of 255 indications derived from common clinical practice or anticipated use for noninvasive vascular testing (ultrasound imaging and physiologic testing). A panel of 19 experts from the various organizations rated 117 (46%) indications as appropriate, 84 (33%) as uncertain, and 54 (21%) as inappropriate. The major highlights of the report are that vascular testing is appropriate when the test is directly related to clinical signs and symptoms. Tests that were unlikely to influence clinical judgment or decision making were considered inappropriate. The group advocated for additional research to determine the usefulness and cost-effectiveness of noninvasive vascular testing for categories with “uncertain” indications. These include appropriateness of carotid duplex ultrasound in patients prior to coronary artery bypass surgery and for assessment of carotid plaque in patients with intermediate Framingham Risk Scores.
The technical panel also reviewed the appropriateness of time points for surveillance tests during the first year after initial diagnosis of pathology and subsequent follow-up across all severity categories. These surveillance tables included review of extracranial cerebrovascular ultrasound, renal and mesenteric artery duplex, aortic and aorto-iliac duplex, and lower extremity artery testing using multilevel physiological testing alone or with duplex ultrasound. Appropriate time interval for follow-up testing after surgical or percutaneous intervention for obstructive vascular disease was also categorized. The panel emphasized that, while the ultimate objective of AUC is to improve patient care and health outcomes in a cost-effective manner, the AUC criteria should not supersede sound clinical judgment for individual patients.
Given multiple guidelines by individual organizations for vascular testing, the wide spectrum of indications for vascular nontesting, the current reimbursement environment, declining health care budgets, and emergence of accountable care organizations in the new health care delivery system, these guidelines provide a useful framework for noninvasive vascular testing for the practicing vascular surgeons, vascular intervention lists, vascular medicine physicians, cardiologists, internists, nurse practitioners, and vascular technologists while also providing flexibility for individualized patient care decisions.