Developing Appropriateness Criteria for Imaging

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Decision support might be the technology that brings imaging out of external control and back into self-regulation, since its effectiveness appears to equal or exceed that of other utilization-management strategies (including burdensome preauthorization). Every decision-support program, however, must be able to tell the ordering physician how useful an imaging exam is likely to be.

That simple indication of probable appropriateness—often a numbered ranking—must be based, in turn, on a prior determination that is anything but simple: Valid appropriateness criteria take into consideration not only expert opinion, but up-to-date research findings and the broadest possible range of relevant clinical experience.

The provision of decision support itself, whether through computerized provider order entry (CPOE) or nonelectronic methods, is relatively straightforward, in comparison with the vast pile of information that must be considered and condensed to create appropriateness criteria. For each patient condition that the referring physician will encounter, the developers of appropriateness criteria must determine not only the degree to which specific imaging exams might be helpful, but also whether imaging is indicated at all. Who makes these decisions today, and how might that change tomorrow?

These were among the questions asked on November 29, 2010, by the four presenters of a special-interest session, “The ACR Appropriateness Criteria: Are You Trying to Tell Me What to Do?” at the annual meeting of the RSNA in Chicago, Illinois. Two of the session’s sections deal with appropriateness criteria and what radiology can expect from them (and contribute to them).

Michael Bettman, MD, vice chair of the ACR® Commission on Quality and Safety, describes how the ACR’s guidelines are constructed by and for radiologists; a prediction that nonradiologists will become more involved in imaging-guideline development is expressed by Earl Steinberg, MD. Steinberg is senior vice president for integrated health strategy and evaluation at WellPoint (Indianapolis, Indiana); president and CEO of WellPoint’s Resolution Health subsidiary; and chair of the US Institute of Medicine’s Committee on Standards for Developing Trustworthy Clinical Practice Guidelines.

ACR Methods

Bettman explains that while the ACR’s appropriateness criteria are meant to guide clinical decisions, they are also intended for use in medical education. For a given clinical condition, the ACR guidelines should tell the physician who is making an imaging decision whether an imaging exam is typically indicated for that condition.

If so, the guidelines then specify whether each exam that could be ordered, under the existing circumstances, falls into one of four categories: usually appropriate, may be appropriate, usually not appropriate, or rarely necessary. Bettman notes that these terms were chosen with care, since the number of variables involved in patient care makes it unrealistic to categorize a study as always appropriate or never appropriate.

In response to growing concern about the cumulative radiation dose attributable to medical imaging, the ACR guidelines now include relative radiation levels (for both adults and children) for each applicable exam. If there are inadequate data on the value of an exam, or if there is disagreement concerning the meaning of those data, that exam will appear in the guidelines as unrated.

The perfect appropriateness criteria, Bettman says, are evidence based and chosen by experts whose methods are both transparent and consistent. They are updated regularly and are available online, as well as within CPOE systems. They also have broad acceptance in the field.

Unfortunately, he adds, all of these are difficult goals to meet. Evidence alone is never sufficient, so expert opinion is always needed. For this reason, the ACR’s method for guideline development involves selecting a topic author to serve as an expert. The topic author then gathers and reviews the relevant medical literature, condensing it into an evidence table that lists the most important published findings (with notes on the quality and reliability of the studies involved).

The topic author also designs clinical scenarios representing the possible and probable imaging orders for the condition being reviewed. The chair of the guidelines panel reviews this material, which is later voted on by the panel’s members before it becomes the official ACR guideline.