New Initiatives for ACR Appropriateness Criteria™
Michael A. Bettmann, MD, and Jeffrey C. Weinreb, MD
As the nation and American College of Radiology (ACR) members are increasingly aware, diagnostic imaging is the fastest-growing physician services expenditure in the United States, with an annual growth rate (9%) that is 3 times that of general physician services (3%).1 ACR data show that legislation or regulation discouraging inappropriate utilization could save billions of dollars over the next decade.
There is broad acceptance for the concept that a clinical decision support program could assist in improving patient care through appropriate procedure selection, resulting in a reduction in inappropriate and unnecessary imaging and associated costs. Fortunately, the leadership of the ACR had the foresight to develop just such a program more than a decade ago—the ACR Appropriateness Criteria™ (AC), and today's leaders are committed to promoting this important program and keeping the AC current and credible.
Third-party payers and vendors among other groups have recently become very interested in using the AC to begin to improve care and reduce costs, through rational use of radiologic services and expertise. Most notable was the announcement in December 2004 by UnitedHealth Group of their intention to encourage the use of AC by the 400,000 providers in its system. In addition, at least 2 presentations at the recent RSNA meeting featured AC in their projects; one from a health system in Israel reported a 2-year decrease in MR and CT utilization of 9% and 32% respectively, and a cost-savings of approximately 3.5 million dollars over the same period.2
As all radiologists are aware, much of the increase in the use of imaging and image-guided procedures over the last decade has come in the form of self-referral by nonradiologists. This also explains much of the increase in the cost to society of these services. Self-referral has become a major contributor, unfortunately, to the inappropriate use of imaging services. We are also well-aware of the accusations of being self-serving when we point out the use and abuse of self-referred imaging services. Although there is no easy answer to the related problems, the AC give us a means to provide a rational guide for the use of image-based services. As the face and the voice of radiology, the interest in the AC gives us, with the help and support of other specialties, the opportunity to provide input and guidance on a broad stage.
In order to be responsive to the increased interest in the AC, significant changes were needed in the development process, format, and dissemination methods. A small group with expertise in database systems worked on converting the AC to a more user-friendly format. The resulting relational database is currently being pilot-tested and the comments that are received will help the College's information services department further enhance the program.
At the same time, a major effort is being made to update the topics and keep them current, starting with those conditions that are frequently encountered or require high-end imaging modalities. This requires an ongoing effort by the more than 200 dedicated expert panel members, and we want to thank them for their continued dedication to this project.
The ACR will be releasing a new edition of the ACR Appropriateness Criteria™, version 2.0, in July 2005 that will feature many updated topics and variants and a user-friendly search engine and that will be accessible through the Web and in PDA applications for Palm and Pocket PC.
As might be imagined, this current effort as well as the work that has gone before is quite resource-intensive, and keeping the AC current and credible will require continued investment in these resources. With the release of the new version, both to protect the intellectual property of the ACR and to enable us to continue to devote the resources required to keep the AC current, all nonmembers and vendors making use of the AC or incorporating them into their systems will need to pay a fee or initiate a licensing agreement with the ACR for continued use of these guidelines. This will enable us to continue to devote the resources required to keep the AC current.
Once the new version is released, continued use of earlier versions of the ACR Appropriateness Criteria™ for imaging or treatment decisions may not reflect current medical practice. It is strongly recommended that use of earlier versions be discontinued after that time. Any use of earlier versions to make imaging and treatment decisions after the publication date of the new edition will occur without the authorization of the American College of Radiology.
These are exciting times for the College, with a clear focus on appropriate utilization as the road to improved patient care. The AC program will play a strong role in forwarding this aim. If you have questions about the AC program, please contact Christine Waldrip at christinew@acr.org.
1 Hackbarth GM, Reischauer RD, Miller ME. Assessing payment adequacy and updating payments for physician services. Medicare Payment Advisory Commission Report to Congress. March 2003.
2 Blachar A, Mandel A, Fridman Y, et al. Preauthorization of CT and MRI Examinations: Assessment of a Managed Care Program Based on the American College of Radiology Appropriateness Guidelines. Scientific Paper, RSNA 2004. http://rsna2004.rsna.org/V2004/conference/event_display.cfm?em_id=4411965