Download Appropriate Use Criteria - Frequently Asked Questions Why were

Appropriate Use Criteria - Frequently Asked Questions
1. Why were AUC originally developed?
 CA Chapter concern over health plan/FBI reviews of PCI and CABG cases in Modesto/Redding by payers
using their own standards and PA Chapter concern over Highmark use of ACR appropriateness criteria
eliminating CV specialists from performing advanced imaging
 MDI (Medical Directors Institute) health plan concerns over imaging growth/cost rates
2. How are AUC technical panels comprised?
 Diversity of clinical viewpoints (ordering physician, general cardiologists, outcomes researcher, procedure
expert, etc) to promote widespread acceptance by physicians, payers, and regulators.
 Final AUC rating is a median score and cannot be weighed down by any one or even several individuals (all
review evidence and existing guidelines)
3. Generally, what types of cases are rated inappropriate?
 Patients without documented symptoms or ischemia
 Low risk patients
 Periodic testing without a change in clinical status or an insufficient time since the last test or procedure
4. How do AUC relate to existing evidence / guidelines?
 AUC are reflections of studies and available data and are consistent with existing guidelines
 Updated every 2-3 years in incorporate changes in the literature and guidelines
 Interobserver testing with duplicate panels have rated indications with high correlation
 Studies of AUC ratings and correlation to outcomes are limited by referral bias; better new studies
5. Do all patients need to have medical therapy prior to elective PCI?
 AUC generally rate cases with documented ischemia or equivalent, including FFR, appropriate
 Only require medications first if Class I/II angina and no or low risk ischemia and no FFR
 Provides case definitions that fit COURAGE/FAME/FAME II/ISCHEMIA/PROMISE trials
6. Should 0% of clinical cases be inappropriate?
 Most institutions/practices are expected to have some percentage of their cases deemed inappropriate
which are justifiable exceptions to general population rules. This is clearly stated in all AUC documents.
7. Should AUC be used for individual patient case review?
 AUC are primarily developed to review patterns of care and based on populations, not individuals
 AUC may be used to help inform or guide physician/patient decision making but are not a mandate to
provide or refrain from care – rather identify mitigating clinical features
8. What are the differences between FOCUS and prior authorization?
 FOCUS is transparent, with ACC setting the standards, and data owned by physician organization, with no
hard denials/appeals
 FOCUS relies on patterns of care, providing feedback and education
9. How do NCDR reports/articles on AUC benefit the profession?
 Reports can help improve data collection and set benchmarks for performance
 Reports can document physician/group/hospital performance and improvement
 Refute reports of overuse
10. AUC in development; not yet published
 ICD/CRT - New Topic
 Diagnostic Cath – New Topic
 Multimodality imaging – New Topic; based in part on single modality AUC