February 16th, 2012

Part 2: Clashing Views of Appropriate Use Criteria for PCI

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In a recent Viewpoint in JACC: Cardiovascular Interventions, Marso and colleagues expressed grave reservations about the application of appropriate use criteria for PCI in a controversial study published last year in JAMA by Chan and colleagues, which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors Rick Lange and David Hillis asked CardioExchange members for their opinions on this topic. In this series of posts, Lange and Hillis question the main protagonists in the debate, Steven Marso and Aaron Grantham, on the one side, and Paul Chan and John Spertus on the other side. All the authors are affiliated with the Saint Luke’s Mid America Heart Institute in Kansas City, Missouri. Click here for Part 1.

Lange & Hillis: The writing group and technical panel for the 2009 AUC and the 2012 update were almost identical (only 1 exception), and only four interventional cardiologists participated in the writing group. Should more (or different) interventional cardiologists be involved in the AUC process?

Chan & Spertus: We believe that the inclusion of a broad range of perspectives in adjudicating the strength of revascularization appropriateness is an asset — particularly because the evidence of benefit should be transparent to all physicians (interventionalists and noninvasive cardiologists alike) caring for CAD patients. In fact, 12 of the 17 panel members are practicing cardiologists who either refer patients for or perform PCI. This is important because the responsibility for a potentially inappropriate PCI should be shared not only by interventionalists performing the procedure, but also by referring physicians.

Contrary to the assertion of Marso and colleagues, the ratings of 85 practicing cardiologists in our paper in JACC correlated exceedingly well with the expert panel, especially given that the latter were able to meet face-to-face to resolve differences of opinion. The interventional members of the AUC technical panel were recommended by SCAI and ACC, and we believe that they should have represented the mainstream perspective of that community; furthermore, the iterative process of determining AUC ratings within the expert panel gave the interventionalist members the opportunity to persuade the rest of the panel if there were indeed compelling data and experiences that should have swayed the appropriateness ratings.

Marso & Grantham: We feel strongly there needs to be broader inclusion of interventional cardiologists in the AUC process. Four is just not enough. We acknowledge that the ACCs current methodology purposefully limits the absolute number of specialty-specific experts involved in the technical panel when creating appropriate use criteria. However, we believe the process would be improved with better representation from interventional cardiologists. Perhaps a way to accomplish this would be for the AUC technical committee to commission a working group of interventional cardiologists to provide direct feedback to the AUC Technical Committee. Certainly, the FDA uses advisory panels when considering drug or device approval decisions. We believe this would be a feasible strategy to broaden participation while limiting the Technical Panel to the RAND criteria. Perhaps it is also time for the ACC to review the rationale for using RAND methodology in establishing AUC documents. The RAND methodology has been around since the 1950s. It is certainly commonly employed in many complex decision-making situations. One wonders, has RAND methodology been consistent and successful in changing physician behavior over the years? Is this the best methodology for the ACC to employ moving forward? To those of us non-RAND experts, it does seem to be rather exclusionary, and its decision-making process less than transparent to outsiders.


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