Finding the Optimum in the Use of Elective Percutaneous Coronary Intervention

The approach used for AUC development appears to be valid, as Class III indications for PCI in the ACC/AHA clinical guideline [24] (Class III = PCI should NOT be performed since it is not helpful and may be harmful) and AUC scenarios rated as inappropriate are in 100% agreement (personal communication, Ralph Brindis, past president of the American College of Cardiology).

Application

It is important to remember that the AUC are intended to aid in patient selection and are not absolute. Unique clinical factors and patient preference cannot feasibly be captured by the AUC scenarios. It should also be noted that the intent of the AUC is not to be punitive but rather to identify and assess variation in practice patterns. To reflect this intent, the terminology applied to appropriateness ratings has recently changed. Clinical scenarios previously classified as “inappropriate” are now termed “rarely appropriate” and clinical scenarios classified as “uncertain” are now termed “may be appropriate.”

Although the AUC were developed to help evaluate practice patterns of care delivery and serve as guides for clinical decision making, they were not intended to serve as mandates for or against treatment in individual patients or to be tied to reimbursement for individual patients. Despite this, health care organizations and payors have used other AUC documents for incentive pay and prior authorization programs, specifically for cardiovascular imaging [25]. Use of the AUC in this manner may still be reasonable if application and measurement is at the level of the practice, rather than the individual patient, but much remains to be understood about the implications of applying AUC in reimbursement
decisions.

Refinement

The AUC for PCI are designed to be dynamic and continually updated. As additional evidence becomes available regarding the efficacy of PCI in specific clinical scenarios, there will be ongoing efforts to update the AUC to reflect this new evidence. This is highlighted by the first update to the AUC occurring less than 3 years after the original publication date [11].

In addition to perpetual review of the data used to inform scenario ratings, there are opportunities to improve measurement of the clinical variables that are considered in rating PCI appropriateness (eg, clinical presentation, symptom severity, ischemia severity, extent of medical therapy, extent of anatomic disease). For example, in the current AUC, symptom severity is dependent on clinician assessment using the Canadian Cardiovascular Society Classification [25]. Moving toward a patient-centered assessment of symptom severity would ensure that the AUC more closely reflect the patient-perceived symptom burden. Further, the use of a patient-centered instrument would reduce the possibility of physician manipulation of symptom severity to influence the apparent appropriateness of PCI. There are similar opportunities to improve reporting of noninvasive stress test data, such as through standardized reporting of ischemic risk. Finally, the use of physiologic assessments of stenosis severity (eg, fractional flow reserve) and quantitative coronary angiography to standardize interpretations of diagnostic angiography may further optimize the assessment of PCI appropriateness.

Application of the Appropriate Use Criteria in Clinical Practice—Study Results