Can appropriate use criteria lead to appropriate care?

T he rapid pace of technological development has brought a wealth of diagnostic and therapeutic options to the care of patients. These new diagnostic and therapeutic tools have dramatically altered medical care but have come with a steep price tag, and it is not clear that the improvement in the quality of care is proportional to the cost of the medical system. In recognition of the fact that there is a significant variation in the use of these tools, and that overuse of diagnostic test may entrain unnecessary expenditures, the American College of Cardiology Foundation has taken on the laudable task of defining appropriate use criteria (AUC) for diagnostic imaging , with the goal of guiding a more efficient and equitable allocation of healthcare resources in cardiovascular imaging. In this issue of Circulation: Cardiovascular Quality and Outcomes, Ye et al 2 report on a study that evaluated the applicability of the AUC for radionuclide myocardial perfusion imaging to a group of 400 imaging studies from their institution. The study involved using 8 individual raters of varying levels of training to assess the appropriateness of the studies according to the AUC, and the results were remarkable in 2 respects. First, the raters agreed that only 61% to 70% of the studies were appropriate. Second, however, they could not agree consistently on which studies these were. Furthermore, the agreement between raters did not differ by level of education or type of physician—cardiology fellows' ratings were no more likely to agree with each other than were ratings by interns. These findings are consistent with earlier studies that show modest to good inter-rater reliability in using AUC to assess appropriate care. 3,4 The study highlights the difficulty in applying the AUC, as they are written, to clinical practice. The challenge is in writing criteria that are simultaneously general enough to account for the complexities of modern medical practice and specific enough to be meaningful. The results from this article suggest that the AUC are failing in at least one of these regards, resulting in variation of interpretation of the criteria. This presents a significant barrier to widespread, consistent implementation of the AUC in practice, which is a prerequisite for the AUC having the desired effect of more efficient and effective use of radionuclide myocardial perfusion imaging. If we stipulate that applying AUC to the decision-making process during test ordering and to reimbursement decisions will …