CMS-approved criteria for cardiac imaging may cause confusion among clinicians
Click Here to Manage Email Alerts
Key takeaways:
- Congress created the Appropriate Use Criteria, or AUC, Program to reduce unnecessary imaging.
- When applied to specific clinical scenarios, many AUC for cardiac imaging provided no guidance on appropriateness.
Appropriate use criteria that have been certified by CMS for coronary artery disease imaging are heterogeneous and, at times, discrepant, according to a review recently published in Annals of Internal Medicine.
The 2014 Protecting Access to Medicare Act established the Appropriate Use Criteria (AUC) Program to reduce unnecessary advanced imaging studies, David E. Winchester, MD, MS, an associate professor in the University of Florida’s division of cardiovascular medicine, and colleagues wrote.
“The program seeks to decrease inappropriate or rarely appropriate advanced imaging tests among Medicare outpatients by mandating the use of AUC accessed through a clinical decision support mechanism,” they wrote. “A prior meta-analysis showed that implementation of AUC in clinical practice increases appropriateness of tests and procedures.”
Organizations looking to develop AUC can apply to CMS and become provider-led entities (PLEs) in the program. However, variable content, formatting and methods of PLE-generated AUC may lead to uncertainty for physicians regarding whether an advanced imaging test is appropriate.
So, Winchester and colleagues conducted a study to review PLE-published AUC focusing on advanced imaging tests for coronary artery disease (CAD) — which CMS has identified as one of eight “priority clinical areas.”
“Several PLEs have developed and published AUC criteria for advanced imaging of CAD,” they wrote. “A prior study comparing AUC from different medical societies in a single patient cohort showed variable assessment of appropriateness for a testing indication, potentially creating confusion for ordering clinicians and adversely affecting patient outcomes.”
Winchester and colleagues found that AUC that have been certified by CMS for CAD imaging can be heterogeneous in their adherence to CMS requirements and discrepant, “creating substantial potential for uncertainty” among physicians trying to provide appropriate imaging to their patients.
“To be qualified as PLEs, organizations are required to adhere to a list of processes specified in detail by CMS that include reporting conflicts of interest, the source of evidence, and the composition of the authorship team,” the researchers wrote. “Our review of publicly available information found that adherence to these basic requirements was inconsistent.”
Of the 17 CMS-qualified PLEs identified, just seven had published AUC related to CAD, and there were substantial variations in the formatting and methods. The number of advanced imaging methods covered ranged from one to 25, and the number of clinical scenarios ranged from six to 210.
In fact, the researchers wrote that some PLEs “have a scope so narrow that it is unclear how their AUC could be translated into a meaningful, comprehensive, clinical decision support system.”
Additionally, when applied to specific clinical scenarios, many AUC provided no guidance on appropriateness — and those that did were conflicting.
“Substantial discrepancies in the scope, methods and formatting of PLE-developed AUC for imaging in suspected CAD leave the AUC program vulnerable to clinician confusion and resistance, possibly risking failure to achieve its intended effect on widespread clinical implementation,” Winchester and colleagues concluded.
Perspective
Back to Top
As a physician practicing in both the primary care outpatient and inpatient setting, one of the most difficult and important conditions to quickly and accurately risk classify is coronary artery disease. When guidelines and the standard of care are unclear or differ between professional societies, it becomes very difficult to figure out what to do. Additionally, for expensive studies or those that require authorization, lack of guidelines can affect whether or not those imaging procedures are reimbursed or an option for patients.
The authors’ investigation into the inconsistencies of AUC recommendations from the listed organizations is an eye-opening assessment of the unintended consequences. On paper, it seems like a well-intentioned, self-determination policy project. Perhaps the answer might be to tighten the accreditation requirements to be listed as a “physician-led organization,” although that also may contribute to the increasing consolidation of influence and authority amongst the largest professional organizations.
Regardless, the article highlights serious issues with this policy that need to be addressed promptly by CMS or legislators.
Collapse
Click Here to Manage Email Alerts