AUC in Catheterization and Percutaneous Coronary Intervention: Challenge and Opportunity

Manesh Patel, MD, an interventional cardiologist at Duke University began by presenting a talk entitled, “Appropriate Use Criteria: The Reasons, Methods, Intended, and Unintended Consequences.” He first pointed out that Medicare expenditures on imaging have doubled between 2000 and 2006. The variation in percutaneous coronary intervention (PCI) outcomes is higher than in other procedures. The economics are staggering with 43 cents of every Medicare dollar being spent on cardiovascular care and 10,000 new Medicare patients created every day. Thus, we must really focus achieving high quality reliable medical care. There is a high correlation between appropriate use criteria (AUC) and current guidelines. In summary, Dr Patel states that we must contain the high cost of spending on imaging, as it is not sustainable, while functional PCI and revascularization are going to remain central to the care of cardiovascular patients. All cardiologists should have a well-defined framework for deciding on high quality cardiovascular procedures in place.

Next, Gregory J. Dehmer, MD, a cardiologist at Texas A&M University College of Medicine presented a talk entitled, “AUC as a Means to Benchmark and Eliminate Unnecessary Variation.” He discussed variations in the use of PCI across the US. He points out that the AUC committee provides a benchmark as determined by fellow physicians and this is likely to be superior to the current profit-motivated claim denial business model with private insurance. He describes the AUC process as thoughtful, thorough and an improvement over the previous system. In conclusion, Dr Patel states that “the AUC is not perfect, but it is improving and evidence they are valid is emerging.”

Kartik Mani, MD, at the Prairie Heart Institute in Springfield, Illinois presented a talk focused on implementing AUC in the laboratory. Criticism was addressed to the ACC National Cardiovascular Data Registry (NCDR) when he had been judged as performing an inappropriate procedure to a patient that most definitely needed the procedure. Going back in the records he found a data entry error. Dr Mani was illustrating how this data entry process can be long and prone to errors, so vigilant attention to detail is clearly important. He further discussed that AUC is important in bridging the guidelines with the individual clinical situations. In conclusion, Dr Mani stressed that keeping track of the number of appropriate/inappropriate cases is the responsibility of the cardiologist. The next speaker also echoed this sentiment as well, stressing that it is not the responsibility of the hospital, the catheterization staff, researchers, or referring physician. It is your responsibility.

Kulon K. L. Ho, MD, cardiologist at Beth Israel Deaconess Medical Center in Boston covered the use of SCAI-QIT toolkit. This is a point of care software that assists the physician in making treatment decisions. An AUC score and indication score are given based on symptoms and other diagnostic criteria. iPhone apps, iPad apps, and web-based platforms are available along with pdf printing for universal paper documentation as well.

The final presentation by Steven Marso, MD, an interventional cardiologist at the University of Kansas Medical Center in Kansas City discussed the role of AUC specifically in preventing the inappropriate use of PCI. He has thousands of man-hours of experience in evaluating and directing a catheterization laboratory. He maintains that you must have regular case reviews and policies in place in order to maintain high quality. He presented data that indicated that nearly half of PCI patients did not even have a stress test. Dr. Marso really emphasized the value in performing fractional flow reserve (FFR) measures since a value of greater 0.8 is clearly significant and interpretable as related to PCI treatment decision making. FFR measures may be incorporated into AUC.