ACC.15: Upcoming PCI AUC take into account past criticisms

SAN DIEGO—Acknowledging there was room for improvement, the authors of PCI appropriate use criteria (AUC) have applied lessons from the last set of guidelines in a revision scheduled for publication this year, a member of the writing committee said.

“The AUC are still fairly new,” Gregory J. Dehmer, MD, of Scott & White Healthcare in Temple, Texas, said March 16 during an American College of Cardiology scientific session. “We are still learning how to apply them. It is a method that is used to assess variation in care. It is not the final arbitrator of care

In 2012, Dehmer along with other cardiovascular subspecialists contributed to a multisociety document on diagnostic catheterizations. The task force scored more than 150 indications as appropriate, uncertain and inappropriate use. Those terms, which were the standard at the time, created some consternation in the cardiovascular community, particularly when they were misinterpreted, misappropriated or distorted.

The AUC were developed proactively by cardiologists to reduce variation and improve the quality of care. Dehmer reminded his peers that the other option would be outsiders dictating to physicians. “There are two alternative technical panels,” he said. “One is Congress and the other is the payers.”   

Publication of the AUC led to some unintended consequences, Dehmer detailed. Specifications that the criteria should not be tied to reimbursement fell on deaf ears, and the misinterpretation of uncertain procedures and lumping them with inappropriate procedures created a skewed public perception of overuse.

“You need to understand that uncertain means there was not enough clinical information available to make a firm determination or, even more importantly, there is not enough clinical, scientific experimental data out there to say clearly which therapy is superior to the other. That is what uncertain means. It does not mean you have done something wrong.”

The wording that will be used in the 2015 guidelines is appropriate, may be appropriate and rarely appropriate. The new language allows for the possibility that a treatment that is rarely appropriate is nonetheless the best option for an individual patient. But if that is the case, the interventional cardiologist should carefully document the encounter.

He added that the AUC also can be used to identify underuse, which can safeguard against not performing appropriate revascularizations. Research has shown that withholding appropriate treatment can increase mortality risk, he pointed out.

“It does provide a benchmark, and they are not perfect,” Dehmer said. “We are working to make them better.”

He emphasized that he was obliged to not share specifics because the new AUC document is under embargo. But the new version will take into account issues identified in the 2012 AUC. “There are many criticisms that the writing group has tried to address in the new AUC.”