In my previous blogs, I have attempted to provide a brief overview of the process and reasons why Appropriate Usage Criteria (AUC) has been developed. One paper published last week and one study presented last week at the American College of Cardiology meeting in New Orleans again highlight the problems we as physicians face in straightening out what we do and why we do it.
In 2009 before the AUC was published, a group of 85 cardiologists from 10 United States institutions were sent 68 of the clinical scenarios that were used from the formulation of the AUC. The purpose was to see whether independent cardiologists came up with the same answers. Be careful what you ask for. As published in J Am Coll Cardiol, 2011:57:1546-1553 and titled Concordance of Physician Ratings with the Appropriate Use Criteria for Coronary Revascularization, this study found that agreement between the groups was 84%. Those procedures deemed appropriate were agreed upon 94% of the time, those procedures uncertain were agreed upon 73% of the time and those inappropriate were agreed upon 70% of the time.
As I have described, acute work for myocardial infarction and unstable angina is easy. This work has shown clear benefit to prolonging and sustaining life. It’s the elective work that is problematic as documentation is often poor and both stress tests and medication is often used in inadequate ways.
At the American College of Cardiology meeting, a study of 500,000 cases were examined from the data base that we use called the National Cardiovascular Data Registry (NCDR) from July 2009 to July 2010. Some of the cases could not be evaluated but of those that could be, 84.6% were deemed appropriate, 4.1% were inappropriate and 11.2% were deemed uncertain. The acute work was deemed 98.6% appropriate. Of the 29% of the cases that were elective, only 50% were deemed appropriate, 38% were deemed uncertain and 11% were deemed inappropriate.
11% may seem like a small number, but would you fly in a plane that had an 11% chance of a problem? The cost of these procedures is high and the benefit small. Further and perhaps most concerning is that the rate of inappropriate procedures varied from hospital to hospital. In other words, it’s not chance. Some hospitals just do more inappropriate procedures. The variation is from under 10% to over 30% in some hospitals.
In response, the NCDR will be sending score cards to hospitals starting this year with a detailed reporting of the rates of appropriate, uncertain and inappropriate along with a report of all the cases that were deemed inappropriate. You can bet they will also be published in some form. Holy Cross hospital reports to this data base and so we will receive ours also.
As you can see, even though these criteria are not universally agreed upon, they are being placed into use both by the government and payers’. This information will help in our, and most hospitals', goal of providing top care in a safe manner. 17 doctors decided all of this, and I hope they were right. This is the beginning of a new era in accountability, and I for one welcome it.