Editorial
Appropriateness Richard H. Daffner, MD, FACR
S
haron Taylor’s recent perspective piece on prior authorization (PA)1 inspired me to “dust off” my plans to comment on a subject that I was intimately involved with for many years – appropriateness of diagnostic imaging. In the early ‘90’s, Medicare, looking for ways to reduce costs, began requiring providers to obtain approval before ordering a diagnostic procedure or implementing certain treatments. The goal was to eliminate unwarranted or inappropriate care. The private insurance carriers (the “Blues”, Aetna, United, et al) quickly followed suit and began their own systems for PA. The use of imaging in medical practice has exploded over the past eighty years. In the 1940’s imaging impacted the diagnosis in one of twelve patients; in the 1950’s, one in six; in the 1960’s, one in three; and in the 1970’s, one in two. By the 1980’s, virtually all patients had some form of imaging performed. With the development of CT and MRI, the costs skyrocketed. Prior to 1970, a fluoroscopy unit was the most expensive piece of equipment in a radiology department. In the 1970s, a CT scanner cost $200,000 on average. As CT evolved and MRI entered the picture, the costs of those pieces of equipment rose dramatically. Today, MRI or PET CT machines can cost upwards of $3,500,000. 8
In 1993, the American College of Radiology (ACR) recognized the need to develop national guidelines for the appropriate use of imaging technologies. These guidelines became the ACR Appropriateness Criteria® 2 (ACR AC®) as a guide for radiologists and, more importantly, for non-radiologists who ordered imaging studies on their patients. The concept was formally presented to the US House Ways and Means Committee by the former chair of the ACR Board of Chancellors, Dr. K. K. Wallace, who stated that the ACR was ready to create these guidelines to help eliminate the inappropriate utilization of diagnostic imaging. In 1994, the ACR formed a task force to begin developing scientifically based guidelines that would be nationally accepted, to assist referring physicians in making appropriate imaging decisions depending on their patient’s clinical conditions. The charge of the task force was to follow acceptable medical practice guidelines used by the federal Agency for Healthcare Research and Quality that had been designed by the Institute of Medicine. The methodology relied on evidence from the scientific literature. In those instances where the data from the literature was insufficient or were inconclusive, the recommendations were based on expert consensus.
Expert panels were selected for each of the eleven areas in diagnostic radiology (Breast, Chest, Cardiac, Gastrointestinal, Interventional, Musculoskeletal, Neurologic, Pediatric, Urologic, Vascular, and Women’s). Members of each panel are nationally recognized experts and leaders in their subspecialty. In addition to radiologists, each panel has physicians from other medical specialties to provide important clinical perspectives. I was a member of the Expert Panel on Musculoskeletal Diseases (MSK) from 1994 - 2011 and chaired the panel from 2006 - 2011. The MSK panel has an orthopedic surgeon, an emergency medicine physician, and a neurosurgeon as our clinical consultants. The goal, as mentioned above, is to produce evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for a specific clinical condition. An additional goal is to maximize the benefits of performing medical imaging and invasive radiologic procedures as well as to minimize risk to patients. Each member of an expert panel submits a list of topics to the ACR staff for them to conduct a search of the literature in Pub Med. The author then assesses the literature and determines www.acms.org
