Appropriate Use Criteria for Coronary Revascularization and the Learning Health System: A Good Start.

Abstract

“Quality,” “safety,” “value,” “cost,” “measurement,” “alignment,” “performance,” “incentives,” “triple aim.” These words and phrases, among others, are now part of the standard lexicon of contemporary health care delivery in the United States. Clinical and scientific journals have published many articles studying and discussing these topics, and the popular press has described the notion of “overkill” in referring to unnecessary medical care.1 A key word in all of these discussions is “appropriate.” According to Hendel et al, “an appropriate diagnostic or therapeutic procedure is one in which the expected clinical benefit exceeds the risks of the procedure by a sufficiently wide margin such that the procedure is generally considered acceptable or reasonable care.”2 Are health care professionals recommending, ordering, or performing diagnostic tests or therapeutic interventions supported by high-quality evidence? Or, as noted in this definition, are they ordering tests and performing interventions more likely to be helpful than harmful? Given the annual cost of US health care, these are important practice and policy conversations. It is known from longstanding research conducted as part of the Dartmouth Atlas Project that tremendous variations exist in cardiology practice across the country3 that are readily explained neither by differences in patient characteristics nor by disease severity. In a field as evidence-driven as cardiovascular medicine, this surprises many who assume that practice guidelines4 provide sufficient recommendations for most of the common conditions and procedures in clinical cardiology. But it is also clear that for the vast majority of diagnostic and therapeutic tests clinicians perform in the daily practice of clinical cardiology, the evidence base lacks sufficient high-quality studies to provide definitive recommendations (classes 1 and 3, the “dos and don’ts” of practice).5 Yet clinicians and patients must still make recommendations and decisions about diagnostic and therapeutic strategies, and policy makers and payers require data on which to base allocations of resources or decisions for reimbursement. The “triple aim” in health care captures some of this as the goal to improve care and health while reducing per capita costs.6 To achieve this laudable goal, the Institute of Medicine has put forward the notion of the learning health care system: “a health care system designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.”7 The American College of Cardiology (ACC) and the American Heart Association (AHA) have an ongoing 30-year commitment to produce clinical practice guidelines to provide the clinical and patient communities with evidence-based recRelated article page 2045 Editorial Opinion