AUC is dead. Long live AUC.

Six months after CMS effectively suspended its Appropriate Use Criteria program, some radiologists are planning to carry AUC principles forward anyway.

Why wouldn’t they? The aims of the program since its 2014 inception were sound: Reduce utilization of low-value imaging while increasing compliance with guidelines on what constitutes appropriate use for various advanced imaging exams.

Another incentive to keep on even without having to: Imaging organizations spent substantial sums on, and dedicated much time to, preparing to meet program mandates. These efforts included the hard work of adopting clinical decision support (CDS) systems.

Alas, official efforts to tie AUC implementation to reimbursement were marked by setbacks and postponements across the program’s 10-year lifespan. Most of the stumbles had to do with the program’s combination of cumbersome processes and limited gains to show for the trouble.

This time the pause appears indefinite if not permanent. CMS has invited providers and suppliers to cease including AUC consultation information on Medicare FFS claims (although claims containing AUC-related codes with dates of service in 2023 and 2024 will continue to process through Dec. 31, 2024).

CMS has also stopped qualifying provider-led entities and clinical decision support mechanisms.

With these developments as backdrop, policy experts at the Journal of the American College of Radiology have organized their thoughts on the subject around a key forward-looking question:

Given the persistent challenge of high levels of low-value advanced imaging use and need to prompt more guideline-concordant testing, what should radiology practices and healthcare institutions keep, dismantle or adapt from their prior AUC efforts?

Here are excerpts from their answers [1].

From the University of Texas Southwestern Medical Center: Bethany Agusala, MD, medical director of the Solomon General Internal Medicine Clinic, and Jhee Lee, MD, medical director at the Parkland Center for Internal Medicine: 

Despite the limitations of AUC as an overall program, there is evidence that using CDS can guide appropriate imaging use in specific settings, such as the emergency department and specialty clinics, or for specific indications such as back pain.

We believe there is still potential for CDS to reduce low-value care and protect patients against unnecessary expenses, wasted time and downstream procedures and complications. In addition, busy clinicians affected by the limits of human memory and rapidly expanding and evolving science can still benefit from technological supports that help align practice with evidence-based guidelines.

Ultimately, the focus on thoughtful CDS should extend beyond the AUC program, leveraging prior work and new flexibilities to create support systems that engage stakeholders and promote better health outcomes and greater equity.

From Intermountain Health: Marta Heilbrun, MD, medical director (system), imaging services, quality & patient safety, and Joseph Bledsoe, MD, senior medical director, urgent care, emergency medicine/trauma/urgent care service line (Canyon Region): 

Just because CMS is no longer rewarding or penalizing health systems for AUC utilization, institutional culture demands that Intermountain continue its path to realizing the benefits of care process models; however, how to do this remains an open question to be answered.

Intermountain Health remains committed to system-wide integration of clinical best practices, as well as understanding and addressing barriers to using AUC algorithms that can help limit low value use of advanced imaging.

Thus far, identified limitations include documents that are hard to find, that are too long and detailed (13 to 40 pages) and are variably integrated into point of care.

Solutions and next steps require active engagement with informatics partners, an ability to leverage information from the electronic health data, embedded guidance in medical charts and flexibility for providers to deliver context-specific care.

From the paper’s authors, led by Christoph Lee, MD, MBA, of the University of Washington in Seattle:

After years of preparation, CMS has effectively ended its AUC program. Institutions must respond to this change and determine if and how to continue or evolve efforts to promote appropriate imaging exam ordering to address the challenge of low-value advanced imaging. In many organizations, mission, vision and culture compel continued effort in in this direction.

However, implementation can be complex, and more work is needed to elucidate benefits of decision support strategies and account for health equity as well as quality and outcomes. CDS should likely continue in specific clinical scenarios and settings where evidence exists for decreasing low-value imaging, and more evidence needs to be generated for or against the continued use of CDS for many other specific scenarios and settings.

Read the whole thing.