Debate Continues with the AUC

MIAMI BEACH, FLA.—Although appropriate use criteria (AUC) have often been utilized to determine the most effective application of interventional techniques in clinical scenarios, the use and abuse of these criteria in dictating protocol remains the subject of debate, according to presentations at TCT 2012.

Adhering to AUC

Spencer B. King III, MD, of the Saint Joseph’s Heart and Vascular Institute in Atlanta, Ga., questioned how confidence can best be ensured in the cardiology profession.

“There are a number of initiatives that have been propagated on both sides of the Atlantic, including quality assurance, as well as peer review, and the necessary creation of guidelines, training standards and expert consensus,” he said. “However, is the creation of definitions of appropriate activity a necessary component of policing ourselves?”

King presented data previously published in the Journal of the American College of Cardiology from 8,168 patients who underwent CABG and 33,970 patients who underwent PCI without ACS or previous CABG surgery in New York in 2009 and 2010, which were used to review appropriateness and to assess the variation across hospitals in ratings of inappropriateness.

Of the patients undergoing CABG surgery without ACS/prior CABG who could be rated, 90.3% were appropriate for revascularization, 1.1% were inappropriate and 8.6% were deemed uncertain. Of the PCI patients eligible for rating, 28% lacked sufficient information to be rated. Of the patients who could be rated, 36.1% were appropriate, 14.3% were inappropriate and 49.6% were uncertain.

“Revascularization for more advanced disease was uniformly rated as more appropriate, and less extensive disease as least appropriate. Because patients with the most severe disease are referred for surgery, almost all of these procedures were in the appropriate category,” King said. “Conversely, since PCI was performed on many patients with less extensive disease, the inappropriate classification was more commonly present in those individuals, under the current criteria definitions.”

Reflecting on appropriateness criteria data

In a review of the data presented in the 2009 Appropriateness Criteria for Coronary Revascularization, Steven P. Marso, MD, of St. Luke’s Health System, Kansas City, Mo., commented on both the underutilization and overutilization of coronary revascularization based on current AUC.

“Variability is commonplace in our country and it’s expected—there is variability if you measure operator level, center level and geographic region,” Marso said. “The question is how much variability is acceptable… there are patient factors that we can measure in outcome research, but there are a majority of patient factors that we cannot. We will never be able to quantify the magnitude of variability that is solely derived from patient demographics.”

In the review, Marso acknowledged the importance of assessing appropriateness for all medical procedures, including PCI, yet cited several concerns with current AUC and methods used to report appropriateness, including an underrepresentation of interventional cardiologists; PCI being deemed an inappropriate indication for Canadian Cardiovascular Society (CCS) class II angina; broad disagreement in the inappropriate indications for PCI between clinicians and the technical panel; and the reliability of stress test reporting.

“In the future, I would ask clinicians to help develop standard operating procedures to more accurately record data from stress test findings, as well as CCS status and anginal equivalence,” Marso said. “I would also encourage the expansion of scenarios and involvement of interventional cardiologists in AUC discussions.”