AUC ‘Here to Stay’ but Should Evolve, Expert Says

Several CV procedures may increasingly require appropriate use criteria (AUC) documentation, yet future utilization of AUC necessitates an evolution toward electronic clinical decision support systems, according to a Hot Topic lecture at TCT 2014.

“There are a lot of good intentions behind the development of AUC, but no good deed goes unpunished,” Kishore J. Harjai, MD, of the Pearsall Heart Hospital at Geisinger Wyoming Valley, Wilkes-Barre, Pa., said. “We’ve seen the slippery slope when we develop criteria, then we start rating each other and developing benchmarks — then public reporting comes in, and we see unintended consequences. I am afraid the development of AUC may actually steal patients [away from] appropriate PCI once we start publically reporting this,” in that cases once rightly considered “appropriate” may not be performed.

Need to evolve

Currently, the format of AUC documents does not promote accessibility and contains controversial recommendations that do not correlate with cardiology guidelines, Harjai said. “The AUC documents have multiple opportunities for improvement,” he noted. “There are issues with their development and a lack of supporting data.”

Inadequate documentation increases the chance for unintended consequences, such as lay press sensationalism and a focus on improving documentation without a corresponding improvement in the quality of care, Harjai said. In particular, he added, the criteria place too much emphasis on stress testing.

Outlier patients who do not fit neatly into the criteria may also pose a problem. There are multiple controversial AUC scenarios that would currently indicate PCI as “maybe appropriate” or “rarely appropriate,” despite trial data that support PCI in these settings, Harjai said.

He cited unpublished data from GHOST investigators who asked four interventionalists to review each other’s interventions for 114 PCIs. The choices were rated “uncertain” 17% of the time and “inappropriate/rarely appropriate” 10% of the time. Furthermore, the reviewing doctors disagreed with the treating physicians 77% of the time on cases deemed “uncertain” or “rarely appropriate.”

“If the interventionalist doctors themselves cannot agree about what is right, it is going to be very hard to identify and manage outliers [with AUC],” Harjai stressed.

An electronic system may improve AUC accessibility. Harjai referred to AUCMonkey.com — of which he is the owner/founder — to help guide physicians through the criteria for determining appropriate interventions.

Drivers of AUC

Despite the many areas with room for improvement related to AUC documentation, the criteria clearly are needed to determine the value of care is clear, Harjai acknowledged. The increasing cost of health care, perceptions of inappropriate care and the terms of the Affordable Care Act (ACA) are a few of the many factors behind the development of AUC through the joint efforts of the American College of Cardiology Foundation and other professional societies, he said.

Harjai reported that the crude prevalence of CV disease is expected to increase 9.9% from 2010 to 2030. However, direct medical costs associated with CV disease will increase 200%, to an estimated $818.1 billion, during this time. He also noted that the United States has outpaced other developed countries in health expenditures per capita and faces extreme regional health care cost disparities.

“In the U.S. health care [system], we are seeing a perfect storm,” Harjai said. “Compared to many other developed nations, the U.S. seems to stand out as having very high costs, but lower life expectancy at birth.”

An increase in hospital settlement claims over unnecessary stenting procedures and greater patient protection under the ACA have also raised the stakes for the rational use of CV procedures through AUC.

“It is very difficult to predict where anything will go in the future,” Harjai said. “But we can be reasonably certain about the fact that AUC will be here to stay.”

Disclosures: 

• Harjai is the owner/founder of AUCMonkey.com and reports financial relationships with AstraZeneca, Boston Scientific and Edwards Lifesciences.