Miller School Study First to Evaluate New ACC Appropriate Use Criteria for Stress Echocardiography

In a study published in the March issue of JACC: Cardiovascular Imaging, a Journal of the American College of Cardiology, Miller School researchers examined for the first time whether the updates in the revised 2011 Appropriate Use Criteria (AUC) for stress echocardiography improved their clinical application and the relation between radiology benefits managers’ pre-authorization guidelines for stress echocardiography and the AUC.

Diagnostic cardiac imaging has come under scrutiny from both government and private payers because its growth rate has significantly outpaced that of other medical services. In response, insurers have imposed pre-authorization requirements for several diagnostic imaging tests to lower costs, contracting with radiology benefits managers to administer these programs. Concomitantly, the American College of Cardiology published AUC for several diagnostic imaging modalities to promote optimal and cost-effective healthcare. However, application of the initial versions of these criteria for some imaging modalities was limited because they excluded a substantial number of potential indications for requesting studies.

In 2011, the American College of Cardiology issued a more detailed version of the AUC for stress echocardiography. Until now, however, these new criteria have not been studied to determine if they are successful in improving application. It was also unknown to what extent the radiology benefits managers’ precertification guidelines for stress echocardiography were consistent with the evidence- and consensus-based AUC.

For the study, “Appropriate Use Criteria for Stress Echocardiography: Impact of Updated Criteria on Appropriateness Ratings, Correlation with Pre-Authorization Guidelines, and Effect of Temporal Trends and an Educational Initiative on Utilization,” principal investigator Howard Willens, M.D., associate professor of clinical medicine in the Cardiovascular Division, Robert C. Hendel, M.D., professor of medicine and radiology, and Katarina Nelson, M.D., a former cardiology fellow, rated the appropriateness of stress echocardiograms using the old and new AUC and determined pre-authorization status according to the guidelines of two radiology benefits management companies already providing pre-authorization services for health plans.

The investigators observed that the revisions in the updated AUC allowed the classification of appropriateness of almost all stress echocardiograms, including those that had previously been unclassifiable using the earlier version. This finding suggests the revised criteria have increased value as both a point-of-care clinical decision aid for providers who refer patients for stress echocardiography and as a guide to reimbursement decisions by insurers and radiology benefits managers.

The researchers also found that the radiology benefits managers’ precertification guidelines were only moderately consistent with the criteria. An additional observation of the study was that there was no change in use of stress echocardiography between 2008 and 2011 or following an educational intervention.

“We need greater dissemination of the improved criteria among practitioners and more cooperation between the radiology benefits managers and the medical societies that write the AUC,” said Willens. “Studies that confirm that the appropriateness ratings according to the AUC relate favorably to healthcare outcomes also are needed to promote their acceptance among practitioners.”

In an editorial accompanying the study, James Min, M.D., associate professor of medicine, imaging and biomedical sciences at Cedars-Sinai Medical Center in Los Angeles and incoming President of the Society of Computed Tomography, explained that although the criteria the managers use are supposedly based on the appropriate use criteria, they have been criticized for making decisions different than the criteria indicate, which can be frustrating for physicians.

In the editorial, Min also wrote that although the study by Willens et al. is an important one, some caveats apply. The investigation did not include an evaluation of stress echocardiography in the community setting where the vast majority of stress echocardiograms are performed and where utilization may be less cost effective than in an academic practice, he said.

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