The American College of Radiology Appropriateness Criteria: Will They Be Useful for Us?

Abstract

In the fall of 1995, the American College of Radiology (ACR) published a series of appropriateness criteria for imaging and treatment decisions.1American College of Radiology Appropriateness Criteria. American College of Radiology, Reston, VA1995Google Scholar These were distributed to the radiology community in the form of a paperback volume, a pocket guideline version, and a CD-ROM. Further copies are available to the interested reader.1American College of Radiology Appropriateness Criteria. American College of Radiology, Reston, VA1995Google Scholar The Health and Science Policy Committee of the American College of Chest Physicians (ACCP) had provided a consultant to the Expert Panel on Thoracic Imaging. It is our purpose here to call your attention to this potentially useful set of guidelines and to briefly outline its content, review how the guidelines were developed, discuss the recognized drawbacks of such work, and point out the positive challenge and opportunity to us that these “appropriateness criteria” represent. The ACR Appropriateness Task Force is composed of ten expert panels. Eight are diagnostic and two are therapeutic. The diagnostic panels are generally organized along organ system lines. The consensus panels include cardiovascular, musculoskeletal, pediatric, thoracic, urologic, women's, gastrointestinal, neuroradiology, interventional radiology, and radiation oncology. The original publication included more than 50 appropriateness criteria coming from 5 of the consensus panels including thoracic imaging. A further publication is expected in the fall of 1996 which will include appropriateness criteria derived from all ten panels. Over 150 appropriateness criteria are either in the process of development or have been completed. Approximately 125 physicians are participating as panelists with representatives from 15 specialty societies other than radiology and another 5 societies have been invited as well. The original ten topics completed by the Expert Panel on Thoracic Imaging included the following: workup of the solitary pulmonary nodule; staging for bronchogenic carcinoma, non-small cell lung carcinoma; routine daily portable radiograph; routine chest radiographs in uncomplicated hypertension; hemoptysis; necessity of rib films for rib factures; dyspnea; acute respiratory illness; acute respiratory illness in HIV-positive patients; and screening for lung metastases. Carl E. Ravin, MD, Professor and Chairman, Department of Radiology, Duke University Medical Center, served as chairman for the Expert Panel on Thoracic Imaging. One of the authors (F.R.B.) served as consultant and voting panel member with 13 radiologists. Since data available from existing scientific studies are usually insufficient for meta-analysis, broadbased consensus techniques are needed for reaching agreement in formulation of the appropriateness criteria. The ACR uses a modified Delphi technique to arrive at a consensus level. Serial surveys are conducted by distributing questionnaires to consolidate expert opinions within each panel. Questionnaires are completed by participants in their own professional setting without the influence of other panel members. Voting is conducted using a scoring system from 1 to 9, indicating the most to the least appropriate imaging examination or therapeutic procedure. The survey results are collected, tabulated in anonymous fashion, and redistributed after each round. A maximum of three rounds is conducted. Eighty percent agreement is considered a consensus; on some issues, no consensus was reached. This modified Delphi technique enables individual, unbiased expression, and is economical, easy to understand, and relatively simple to conduct. All of the criteria are to be reviewed every 3 years, or earlier, if highly significant new scientific data are introduced in the interim. With publication of the guidelines, the ACR Task Force went to great lengths to explain that these criteria are intended to guide radiologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient's clinical condition should dictate the selection of appropriate imaging procedures or treatments. Other imaging studies necessary to evaluate other coexisting diseases or other medical consequences of this condition are not considered in this document. The task force went on to state that the availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination. It was specifically stated that ACR appropriateness criteria are not designed as a guideline for third-party reimbursement. The criteria were also discussed in a focus session at the annual meeting of the Radiology Society of North America2Radiologic Society of North America Special Focus Session, ACR appropriateness criteria for imaging and treatment decisions, Presented at the 81st Scientific Assembly and Annual Meeting of the Radiologic Society of North America, 1995, Chicago, IL, Nov 26-Dec 1Google Scholar in an attempt to describe how these criteria were meant to be helpful and not threatening to practicing radiologists. Clinical practice guidelines are becoming a prevalent part of the health-care scene. In 1990, there were 26 physician organizations developing 700 guidelines; by 1992 the number had increased to 45 and 1,500 respectively.3Walker RD Howard MO Lambert MD et al.Medical practice guidelines.West J Med. 1994; 161: 39-44PubMed Google Scholar There is some evidence that practitioners may be slow to adopt these types of recommendations into their daily practice because of inherent skepticism about the ulterior motives of such guidelines. Guidelines are often viewed as the imposition of an academic perspective on the practicality of real-world patient care.4Fein AM Niederman MS. Clinical commentaries: guidelines for the initial management of community-acquired pneumonia: savory recipe or cookbook for disaster?.Am J Respir Crit Care Med. 1995; 152: 1149-1153Crossref PubMed Google Scholar Also of importance is the medicolegal implications of this type of work. The primary value of practice guidelines is not their use in litigation but their use in practice.5McIntyre KM. Medicolegal implications of consensus statements.Chest. 1995; 108: 502-506Abstract Full Text Full Text PDF Scopus (12) Google Scholar The ACR effort in developing appropriateness criteria is multidisciplinary. The number of participating specialty societies is increasing over time. This adds to the validity of the consensus process. In addition to developing these criteria, implementation will also have to be multidisciplinary if it is to be effective. As the criteria are absorbed at the local level, the statements ideally should be reviewed across affected departments to make minor adjustments for unique local circumstances. It is hoped that these criteria will be viewed for what they are, a recommendation to maintain quality of care while helping to reduce unnecessary costs. In our opinion, therein lies our challenge and opportunity. We respectfully recommend that you review these appropriateness criteria in relation to your practice setting. The criteria are not official policy of the ACCP. Whether you initially judge them applicable or nonapplicable, the best approach would be to attempt to validate (or invalidate) the criteria through systematic use. Your results should be fed back to the American College of Radiology and to scientific forums such as this journal. If all of us accept this challenge, these criteria may evolve into valuable evidence-based guidelines that will improve our patient care approach.