Appropriate Use Criteria: Health IT Creates Gateway for Gatekeepers

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The growth in imaging study volume has come under fire in recent years. The figures are staggering. Advanced imaging services spending by Medicare, including for CT, MRI and nuclear medicine, increased from $3.6 billion to $7.6 billion from 2000 through 2006, representing a 17 percent average increase annually. U.S. expenditures on medical imaging are approaching $100 billion.

The American College of Radiology (ACR) Appropriateness Use Criteria (AUC) provides a mechanism for curbing growth by seeking to determine if a particular imaging exam is appropriate for a specific patient condition. While clinical implementation of these protocols has been slow, the increased deployment of health IT may facilitate greater adoption of AUC. Early feedback from sites that have leveraged IT to support appropriate exam ordering is positive. However, widespread implementation hinges on education, sustained commitment from professional societies, incentives and perhaps, legislation.

Where are we now?

Begun in 1993, the ACR AUC covers 167 topics. The criteria have been developed by 10 diagnostic imaging expert panels and an interventional radiology panel, in conjunction with 20 medical specialty organizations. Since 2005, the ACR, along with the American College of Cardiology (ACC) and other societies, have developed several appropriate use protocols for each of the major cardiac imaging modalities, including SPECT myocardial perfusion imaging, cardiac CT, cardiac MR and stress echocardiography.

“In the last five years, the level of collaboration between the professional societies to develop superior AUC best practices has skyrocketed,” notes James H. Thrall, MD, ACR president and chief radiologist at Massachusetts General Hospital (MGH) in Boston.

Despite these efforts, widespread AUC adoption is still in its “very early stages,” says Todd D. Miller, MD, of the nuclear cardiology department at Mayo Clinic in Rochester, Minn. While clinical studies suggest the inappropriate use level of cardiac SPECT is 15 percent across the U.S., for example, Miller suspects that it must be closer to 50 percent in some practices because of the national rate of imaging growth. Similarly, a retrospective review of 459 CT and MRI studies to determine AUC usage pegged 74 percent as appropriate and 26 as not appropriate (J Am Coll Radiol 2010;7:192-197).     

To combat inappropriate use of imaging, professional societies are working for better dissemination and improved adoption of AUC. The ACR recently posted protocols online and made them available for handheld devices. The ACC launched the FOCUS initiative to help practices best use AUC at the point of care; the online community provides a forum for participants to share ways to maximize AUC use and includes educational resources.

The effort also extends to individual institutions. Hospitals such as MGH have built the ACR Appropriateness Criteria into computerized order entry (CPOE) systems.

However, the lack of mandate to implement AUC creates a conundrum. The burden lies on the individual radiologist, practice or department to adopt protocols, which may contradict the bottom line. “Traditionally, radiology practices and departments have been asked to open access as much as possible, encourage throughput as much as possible, generate as much revenue as possible—all while maintaining a high level of efficiency and maximizing the business,” explains Alexander M. Norbash, MD, chief of radiology at Boston University Medical Center. “This kind of a fee-for-service attitude runs counter to considering how equipment can be best utilized for each individual patient, and to only perform imaging tests when necessary.”

“Only recently have radiologists been in the position of rejecting inappropriate studies. For the radiologist to become a ‘gatekeeper,’ who oversees appropriateness and is empowered to divert or cancel a significant percentage of studies, it will require a dramatic change in the traditional role, especially when we contrast this new role with that of the radiologist as an imaging facilitator,” Norbash adds. For this transition to occur, he suggests that referring physicians will have to become equally educated about AUC protocols to “work as a unified team with the radiologist.”

The health IT foundation

To properly utilize AUC protocols at the point of care, most physicians concur that health IT is necessary.

Until EMRs and CPOEs become more widespread, the adoption of AUC at the point