Doll and Patel publish editorial on appropriate use criteria

March 11, 2015 – Jacob Doll, MD, and Manesh Patel, MD, argue that AUC must be constantly updated with new data to be useful.

The DCRI’s Jacob Doll, MD, and Manesh Patel, MD (pictured), recently penned an editorial for the Annals of Internal Medicine on appropriate use criteria (AUC).

AUC are intended to help clinicians interpret the data available to them and guide patient care decisions. In a study published in the same issue of the Annals, researchers frommanesh-patel-news Sunnybrook Health Science Center in Ontario, Canada, found that approximately one-third of patients with diagnostic angiography deemed “inappropriate” under current AUC actually had obstructive coronary artery disease, and more than 40 percent with “appropriate” angiograms did not.

An analysis of outcomes from approximately 50,000 procedures in a Canadian registry revealed that among the roughly one in 10 patients with angiography deemed inappropriate, 30.9 percent had obstructive coronary artery disease and 18.9 percent underwent revascularization.

This study illustrates both the opportunities and challenges of applying AUC to large sets of data, according to Doll and Patel. In the Sunnybrook study, the registry was missing the information required to correctly assess appropriateness, specifically whether a patient’s chest pain was typical or atypical and whether stress testing categorized patients as intermediate-risk.

These findings, in Doll and Patel’s words, “highlight the need for ongoing maintenance of AUC with an iterative process that incorporates new evidence from clinical trials and quality improvement initiatives.”

They suggested that clinicians consider AUC when ordering a cardiovascular imaging test or catheterization, but note that more work is needed to better integrate AUC and large data sets into contemporary clinical practice.

Doll and Patel concluded that although there is interest in “systems that use big data to assess appropriateness in order to reduce costs,” AUC have value beyond this limited use.

“An ideal system would be evidence-based, use uniform and comprehensive clinical data, provide point-of-care decision support and aim to improve quality by reducing overuse and underuse,” they wrote. “The AUC could be the backbone of such a system and, if trusted by all stakeholders, could provide a practice-level alternative to pre-authorization requirements or indiscriminate reductions in reimbursement.”