You've heard about ACR Appropriateness Criteria® and clinical decision support. Here's why you should pay attention.
Imagine you are new to a place and looking to take your friends out to dinner. Everyone has different ideas about where they'd like to eat, so you head to the Yelp app for restaurant reviews.
Your best friend wants that Asian restaurant on the corner, but its average reviews come out to less than three stars and the service is said to be slow. Your mother wants to go to a French restaurant, but it's expensive and most reviews say it isn't worth the price. Your choice, a medium-priced Italian restaurant, has a variety of food options and solid reviews — so it's the most appropriate choice for everyone. You've made your decision quickly and without fuss.
What does this have to do with medicine? Just as ratings might dissuade you from visiting a restaurant, the rankings of imaging tests in the ACR Appropriateness Criteria® (AC) dissuade referring clinicians from ordering inappropriate imaging. And by incorporating the AC into its framework, the clinical decision support tool ACR Select™ takes the AC into the digital world, making them more widely accessible for the entire health care team.
Ordering the correct procedure for each indication can be a daunting task for anyone; not only do you have to make sure your decisions align with the constantly updating research on a given topic, but you have to ensure that your choice is the best and most appropriate test for your patient. To help referring clinicians do that, the ACR has created the AC, a longstanding effort to provide systematic evidence-based guidance to aid physicians in ordering the right tests at the right time.
The AC are vast, covering over 200 topics. Each topic covers a medical condition that prompts physicians to order imaging. These are drilled down even further into variants, or subtopics. How much volunteer effort does it take to research all these? Quite a lot, actually; more than 300 panel members review the current literature surrounding each topic. These members are divided into two groups: diagnostic and interventional radiology, and radiation oncology.
After reviewing the most up-to-date literature on the topic, panel members rate which imaging tests are most appropriate for each topic and its variants.
Although many organizations produce guidelines, few appropriateness criteria are as comprehensive as the ACR AC. "Often, other medical societies might put together a group to review, at most, a handful of topics for appropriate utilization. The ACR is the only society to take on this huge range of material," says E. Kent Yucel, MD, FACR, chair of the Diagnostic and Interventional Radiology AC Committee. He adds that such broad coverage is important because it's difficult for radiologists to stay on top of the literature for every subspecialty. If a radiologist does not believe a referring physician is making the right imaging decision, the AC can serve as evidence that a discussion
is warranted. The AC are also listed in the National Guidelines Clearinghouse; due to its strict inclusion criteria, not all societies' AC make the cut.
Part of the Whole
Because they span so many topics and subspecialties, the AC make up a vast tool, comprising hundreds if not thousands of pages of research and ratings. But in today's fast-paced world, how can you get to the right topic quickly without having to navigate a large mass of information? Enter ACR Select™, the clinical decision support (CDS) tool that incorporates the diagnostic radiology portion of the AC. (Need a refresher on CDS? Visit the October 2012 Bulletin.) ACR Select aids referring clinicians by pulling portions of the AC into a larger body of knowledge that will include other information, such as recommendations from the Committee on Incidental Findings. Yucel explains, "Basically, we're feeding information streams (like the ACR AC) into this larger river called ACR Select. Although the AC are a central component of ACR Select, they're a piece of this larger instrument."
While the medical community has long seen the value of CDS, the government has also turned its eye to the benefits in recent years. Included in the recent sustainable growth rate legislation is a mandate that, beginning in 2017, in order to receive reimbursement, all referring clinicians must consult government-approved, evi- dence-based appropriate-use criteria before ordering imaging. The legislation further stipulates that refer- ring physicians use appropriateness criteria created by medical societies, such as the ACR. By making the ACR AC available within ACR Select, the ACR positions
radiologists as the source behind a now critical tool. This allows radiologists to be more visible as a resource for their referring physicians, says Bob Cooke, head of marketing and strategy for the National Decision Support Company, which distributes ACR Select.
CDS can also be used as an alternative to prior authorization for imaging. Replacing the current prior authorization process with ACR Select can save time and money, not only for patients and clinicians, but also for the health care system as a whole. By implementing ACR Select, practices can eliminate the costs of radiology business management companies (and the time it takes providers to interface with them for prior authorization). (Read an Imaging 3.0™ case study about how one group used CDS to meet new radiology business management mandates.)
This, says Cooke, allows for better working relationships between radiologists and referring clinicians. "By supporting tools like these, you're supporting self-managed utilization for physicians, which simplifies the ordering process for imaging and allows our clinician colleagues to spend more time with their patients," he adds.
Saving money and helping referring clinicians is critical, but at the end of the day, using tools to facilitate appropriate imaging is just the right thing to do, says Yucel. By helping clinicians select the right imaging tests at the right time, radiologists add value throughout the health care system. "By creating the AC and then making them more accessible for everyone, we're saving patients time and money, we're allowing doctors more time to focus on their patients, and we're making sure that patients only get the imaging they need," says Yucel. "That's working for a greater good."
But if radiologists do not capitalize on this valuable resource only they can provide, if they refuse to support the ACR's efforts to produce the criteria the CDS tools are based on, radiologists will lose their chance, warns Yucel. "The ACR is providing a service that is critical as we move forward into value-based health. And while we are at the top right now, it's a tenuous position," he says. "Right now, the ACR and radiologists are the recognized leaders in the decision-making process. If we don't provide this tool, then others will. Insurers and other specialties would gladly take it on and cut us out of the process."
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Getting the Word Out
While clinical decision support focuses on the ordering of diagnostic radiology studies, the ACR's Radiation Oncology AC Committee is also hard at work to develop the best appropriateness criteria (AC) for radiation oncologists as well. Like the rest of the AC, radiation oncology is extremely robust in its updating process, says Benjamin Movsas, MD, FACR, chair of the Radiation Oncology AC Committee.
With each review, the panels add new, relevant material supported by the latest literature. According to Movsas, at least 14 new topics are being added to the radiation oncology AC this year. This is beyond the 50 current topics in radiation oncology AC, ranging from lung, breast, head and neck, and prostate cancers, to bone and brain metastases. Movsas adds that their
evidence-based information is disseminated through many published articles in a variety of journals, such as JACR®, Oncology, and the American Journal of Clinical Oncology, among others. The radiation oncology AC topics can be found in the ACR Journal Advisor™.
Getting this information out to the right people as quickly as possible is the right thing to do, says Movsas. "We're in an era right now where you really have to think about the resources we have and how to use them appropriately and efficiently. The radiation oncology AC really help in that regard. For example, if there's no evidence that a higher dose of radiation is beneficial in a particular setting, not only is using the higher dose potentially harmful, it's an unnecessary use of resources," he says. For more information on the radiation oncology AC, visit the AC website.
Check out the ACR Appropriateness Criteria at ACR 2015
Want to learn more about the ACR Appropriateness Criteria? Check out the session "An Inside Look at Developing ACR Appropriateness Criteria (AC) for Radiation Oncology" at ACR 2015. The session will analyze the process for developing the AC, including holding an exercise that demonstrates how the methodology behind the AC works. "We want to give participants a real flavor of what we do and how we do it. We're going to be looking particularly at the AC and lung, head, and neck cancers," says Benjamin Movsas, MD, FACR, chair of the Radiation Oncology AC Committee. Check out the session here.
Meghan Edwards is a copywriter for the ACR Bulletin.