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 is a reasonable approach for the indication
4-6: Maybe Appropriate (M) or unclear if appropriate for specific indication
• Procedure may be generally acceptable and may be a reasonable approach for the indication
1-3: Rarely Appropriate (R) procedure for specific indication
• Procedure is not generally acceptable and is not a reasonable approach for the indication

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