Utilizing AUC in Practice: What Do You Do with the Yellow

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Utilizing   AUC   in   Practice:   What   Do  

You   Do   with   the   Yellow   Boxes?

Larry   S.

  Dean,   MD

Professor   of   Medicine   and   Surgery

University   of   Washington   School   of   Medicine

Seattle,   WA

I   have   nothing   to   disclose   with   regard   to   this   presentation

Appropriateness of Cardiovascular

Procedures

Ranking of Indications

7-9: Appropriate (A) procedure for specific indication

• Procedure

is

generally acceptable and reasonable approach for the indication

is

a

4-6: Maybe Appropriate (M) or unclear if appropriate for specific indication

• Procedure

may

be generally acceptable and a reasonable approach for the indication

may

be

1-3: Rarely Appropriate (R) procedure for specific indication

• Procedure is

not

generally acceptable and is reasonable approach for the indication

not

a

May   Be   Appropriate:   AKA   Uncertain

The   rating   of   uncertain   is   used   when   pertinent   literature   is   either   not   available   or   when   true   discrepancies   exist  

It   is   impossible   to   include   every   relevant   piece   of   clinical   information   (e.g.,   age,   sex,   diabetes)   in   the   individual   clinical   scenarios

The   writing   group   emphasizes   that   uncertain   indications   are   not   inappropriate  

Appropriate Use of Cardiovascular

Procedures

Maybe Appropriate Category

Does NOT indicate that the procedure should NOT be performed for that indication, but rather more information/research is need to reach a firm conclusion

Does NOT indicate that the procedure should not be reimbursed for that indication

2012   AUC:   Focused   Update:   New   or  

Revised   Indications  

AUC:   ACS

2012   AUC:   Chronic   Ischemic   Heart  

Disease

2012   AUC:   Chronic   Ischemic   Heart  

Disease

2012   AUC:   Chronic   Ischemic   Heart  

Disease

012   AUC   Focused   Update:   Method   of  

Revascularization

Application   of   AUCs

Excellent   for   ongoing   review   of   one’s   practice   and   using   the   criteria   will   help   guide   a   more   effective,   efficient,   and   equitable   allocation   of   healthcare   resources,   and   ultimately,   better   patient   outcomes   

Limitations   of   AUCs

Appropriate   use   criteria   are   intended   to   assist   patients   and   clinicians,   but   are   not   intended   to   diminish   the   acknowledged   difficulty   or   uncertainty   of   clinical   decision   making   and   cannot   act   as   substitutes   for   sound   clinical   judgment   and   practice   experience

They   identify   common   clinical   scenarios—but   they   cannot   possibly   include   every   conceivable   patient   presentation.

 

AUCs: Clinical Judgment – With

Suggestions

Appropriate Use Criteria are not substitutes for sound clinical judgment and practice experience.

In situations where there is substantial variation between the appropriateness rating and what the clinician believes is the best approach for a specific patient, further considerations may be appropriate.

What   Do   You   Do   with   the   Yellow  

(Maybe   Appropriate)   Boxes?

First   step   is   to   make   sure   your   documentation   is   adequate   to   support   the   procedure   and   is   present   in   the   medical   record

Know   the   AUC   cold

For   all   of   us   who   can’t   meet   that   expectation   use   a   tool   such   as   the   SCAI   online   AUC   tool

Better   documentation   my   allow   you   to   meet   a   clinical   scenario   that   is   appropriate

If   despite   all   this   the   patient   is   still   in   a   yellow   box   then   clearly   document   your   clinical   reasons   for   doing   the   procedure

Moving   from   Maybe   to   Appropriate

Appropriate   angina   assessment:  

CCS

ACS   vs stable   ischemic   heart   disease

Maximal   antianginal   medical   therapy   is   defined   as   the   use   of   at   least   2   classes   of   therapies   to   reduce   anginal   symptoms http://scai ‐ qit.org

.

  

AUC   ACS:   NSTEMI

AUC   ACS:   NSTEMI

AUC   ACS:   NSTEMI

AUC   ACS:   NSTEMI

AUC   ACS:   NSTEMI

AUC   ACS:   NSTEMI

AUC   ACS:   NSTEMI

How   to   Make   Sure   You’re   Appropriate

Know   the   definitions:

CCS   angina   class

ACS

STEMI

NSTEMI

UA

Non   invasive   risk   assessment

Antianginal   medications

Extent   of   disease   (   > 70%   (50%   LMCA)   and   SYNTAX   score)

Use   FFR   if   the   lesion   is   <   70%

Procedure   Report:   One   Example  

ACS

NSTEMI   with   one   of   the following: HF,   +markers,   EKG   changes,   or   ongoing   chest   pain

STEMI   <   12   hours

STEMI   >   12   hours   with   ongoing   ischemia/HF

Elective   PCI

CCS   class:  

On   2   or   more   classes   of   antianginal   meds

(Betablocker,   Ca ‐ blocker,   ranolazine,   long   acting   nitrate,   other)

Stress   testing?

Ischemia:   Mild,   Modor Severe

Coronary anatomy/prior revascularization:  

Other   indications:  

AUC:   Reasons   They   May   Become   More  

Important

Mercer   Letter   to   UWMC

Who’s   involved:   Microsoft,   Boeing,   Costco,   Starbucks,   etc.

What’s   This   All   About?

Value   Based   Purchasing:   The   Value   Equation:   Value   =   Quality/Cost

AUC   Conclusions

Designed   to   provide   evidence   based   care   and   can   serve   as   a   metric   for   quality

Require   an   in   depth   understanding   of   the   definitions   used  

Are   not   all   inclusive   of   patient   presentations

Should   not   be   used   to   determine   coverage….but

  remember   the   value   equation  

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