Clinicians need to get on board with appropriate use criteria (AUC) for cardiac imaging, according to a group of multi-institutional researchers.
The use of some cardiac imaging procedures in the U.S. has gone down, but published literature still reveals rates of "rarely appropriate testing in various types of imaging," wrote Rami Doukky, MD, of the John H. Stroger Jr. Hospital of Cook County in Chicago, and colleagues.
The Centers for Medicare and Medicaid (CMS) is the process of implementing an aspect of the Protecting Access to Medicare Act (PAMA) of 2014 that will introduce a new framework for applying AUC, the authors stated in an opinion piece in the Annals of Internal Medicine.
As a result, AUC implementation should no longer be viewed as an "idealistic academic exercise," they stated.
The authors pointed out that "various professional medical organizations have developed [AUC] to guide physicians and payers on effective use of these procedures." In addition, computer-based clinical decision-support mechanisms (CDSM) have been deployed in some electronic health record (EHR) systems.
In 2018, PAMA will require ordering physicians to consult AUC using a CMS-approved CDSM when ordering advanced imaging procedures (such as radionuclide imaging, magnetic resonance imaging, and computed tomography); echocardiography has been exempted," the authors noted.
They acknowledged that "Most cases of rarely appropriate testing (perhaps >90%) conveniently stem from a few clinical scenarios," singling out stress echocardiography and stress radionuclide imaging, transthoracic echocardiography, coronary CT angiography, and cardiac MRI as "common rarely appropriate uses of cardiac imaging procedures."
They added that targeted educational interventions, such as scholarly communications and online case-based scenarios, could reduce such inappropriate testing.
With the PAMA change, "A massive shift will occur wherein the burden of reducing inappropriate use moves largely from payers to providers," Doukky's group cautioned. "Most physicians are unprepared for this paradigm shift."
They called for close collaboration between professional groups that represent referring providers and imaging specialists to raise awareness among all stakeholders of the expectations under PAMA. The authors also pointed out that currently available CDSMs are often "disjointed from the care process," and need to be integrated more seamlessly into EHR systems to provide real-time guidance with the least provider burden.
Doukky disclosed relevant relationships with Astellas Pharma. Co-authors disclosed relevant relationships with Novartis Institutes for Biomedical Research, Astellas, INVIA Medical Imaging Solutions, Bracco Diagnostics, Ionetix, and the American Society of Nuclear Cardiology.
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