Medical Imaging: Appropriate Use Mandate Coming Into View

Implementation of appropriate use criteria in imaging studies for cardiac patients "is no longer an idealistic academic exercise," researchers say, and may eventually extend to other areas of medicine.

It's time for clinicians to prepare for a coming federal mandate on the appropriate use of medical imaging technology, according to an opinion piece in Annals of Internal Medicine.

The paper, "Promoting Appropriate Use of Cardiac Imaging: No Longer an Academic Exercise," notes that the Centers for Medicare & Medicaid Services is in the rulemaking process to implement part of the Protecting Access to Medicare Act (PAMA) of 2014, which will guide clinicians in applying appropriate use criteria (AUC) for imaging procedures.

In 2018, PAMA will require physicians to use a CMS-approved clinical decision-support mechanisms to consult AUC when ordering certain advanced imaging procedures.

The AUC aim to help physicians use available evidence or expert opinion to decide which patients should get which testing, or sometimes alternative tests or no tests at all. Testing appropriateness falls into three categories, depending on the clinical scenario:

1. Appropriate (established value)
    
2. May be appropriate (uncertain value)
    
3. Rarely appropriate (no clear value)

CMS will also collect data, and after two years of doing so will identify "outlier" physicians, who will be subject to prior authorization, "thus possibly limiting patients' and physicians' access to advanced imaging procedures," the authors write.

The goal of AUC is to avoid excess costs, as well as to enhance "the value of imaging in risk stratification and decision making" and reduce radiation risk, particularly in women, all as part of a total disease management plan.

Using clinical decision-support mechanisms that are integrated in electronic order entry systems can help clinicians make these decisions. The authors point out that in "a prospective trial, use of a point-of-care CDSM reduced inappropriate use of all cardiac imaging modalities from 22% to 6%, whereas use of medical therapy increased from 11% to 32% (both statistically significant)."

CMS has finalized eight "priority clinical areas," which will be used to benchmark providers according to their use of rarely appropriate imaging procedures. They are:

1. Suspected or diagnosed coronary artery disease
2. Suspected pulmonary embolism
3. Headache
4. Hip pain
5. Low back pain
6. Shoulder pain
7. Suspected or diagnosed lung cancer
8. Neck pain

CMS has also identified 11 qualified "provider-led entities" that have developed or endorsed applicable AUC. They are:

1. American College of Cardiology Foundation
2. American College of Radiology
3. Brigham and Women's Physicians Organization
4. CDI Quality Institute
5. Intermountain Healthcare
6. Massachusetts General Hospital, Department of Radiology
7. National Comprehensive Cancer Network
8. Society for Nuclear Medicine and Molecular Imaging
9. University of California Medical Campuses
10. University of Washington Physicians
11. Weill Cornell Medicine Physicians Organization

The authors note that despite the pending mandate, there are still many questions to be answered, including how CMS will define "outlier" physicians; the requirements for reporting and submitting claim forms; whether the free version of a CDSM is easy to integrate into clinical workflow; the effect on small practices unable to implement a CDSM; whether primary physicians will bypass AUC; whether PAMA will deter developing AUC in new fields; and how the mandate will affect patient outcomes.

Despite the uncertainty, the authors argue that the time is now to prepare for the mandate.

"Most physicians are unprepared for this paradigm shift," they write.

"Critical to the success of this effort is the involvement of all stakeholders—from imaging specialists to primary care providers, training programs, payers, health systems, and patients—to fully realize the benefits of AUC and extend them to other areas of medicine."