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Rush North Shore Medical Center Skokie, IL 60076 Rush Medical College Chicago, IL 60612
I share with Drs. Tigges, Sutherland, and Manaster their disappointment on finding that only 30% of surveyed radiologists use musculoskeletal appropriateness criteria [1]. However, although I do not doubt the accuracy of the researchers' findings, I do question a portion of their conclusion. The authors write that the low utilization of the criteria "is consistent with other reports in the literature that show little impact on the practice of physicians after the distribution of written practice guidelines." The authors seem to have incorrectly equated appropriateness criteria with practice guidelines. In fact, these two programs are quite separate and distinct.
About 15 years ago, medical societies and professional organizations began providing consistency and objectivity to the process of determining the standard of medical care in given situations by formulating practice guidelines known by various terms, including "parameters," "algorithms," "clinical indicators," "clinical pathways," "caremaps," and "standards" [2]. To provide guidance for practicing radiologists regarding the best way to perform radiologic procedures and to govern quality in all aspects of radiologic imaging and radiation oncology, the American College of Radiology (ACR) in 1990 introduced its own practice guidelines, called Standards [3]. Although the published ACR Standards contain a disclaimer that the standards are "not rules" but rather "defined principles of practice which should generally produce high-quality radiologic care" [4], the standards are considered by many professionals and lay people as mandatory regulations [5].
The Canadian study to which Tigges et al. [1] referred dealt with practice guidelines rather than appropriateness criteria and found that "the rates of cesarean section were not significantly changed after distribution of guidelines [italics added] designed to reduce the number of this procedure" [6, 7]. The practice guidelines referred to in the two articles were developed by the Society of Obstetricians and Gynecologists of Canada in 1986 stated explicitly that the existing rate of repeated cesarean sections was unacceptably high and listed specific recommendations as to how to decrease the rate. The review article abstract to which Tigges et al. referred also apparently dealt with practice guidelines rather than appropriateness criteria [8].
The ACR Appropriateness Criteria, on the other hand, were developed in 1995 to assist and guide radiologists and referring physicians in deciding which imaging technique or therapeutic regimen is best for specific clinical conditions [3, 9]. Practice guidelines—and in particular ACR Standards (in contrast to appropriateness criteria)—bear directly and exert great influence on judges or jurors who must determine whether a defendant radiologist in a given malpractice case has breached the standard of care [5]. All radiologists should be familiar with and adhere to these standards, and radiologists who find that they must depart from them in a specific case should document their reasons for doing so.
The ACR Appropriateness Criteria are indeed the product of numerous radiologists under the leadership of Philip Cascade, all of whom voluntarily contributed countless hours developing the criteria, and remain an invaluable resource for radiologists [9]. However, the criteria are (in contrast to the standards) advisory only and as yet have not achieved any legal status.
I do not in any way wish to minimize the importance of appropriateness criteria, and I agree with Tigges et al. [1] that more effective ways must be found to ensure that the criteria remain useful to radiologists in their day-to-day practice. I might add that the criteria have been useful to my associates and me. Our own practice was recently audited by a Medicare investigator for possible upcoding violations. After an adverse determination was made by the investigator, we proceeded to a Fair Hearing, using many portions of the ACR Appropriateness Criteria [9] to defend our original coding. Ultimately, the Fair Hearing Officer reversed the earlier findings and ruled in our favor. Although I cannot state with certainty that our referring to the appropriateness criteria was the sole reason for the reversal, I do believe that it played no small role in our being able to successfully defend our coding process.
References
Emory University School of Medicine Atlanta, GA 30322
University of Colorado Health Sciences Center Denver, CO
80262
It is true that practice guidelines and appropriateness criteria, although sharing a similar purpose, are not identical. We compared our findings with the experience of the Society of Obstetrics and Gynecologists of Canada to reinforce how difficult it is to change physician behavior simply by presenting them with printed educational material. It was not our intention to equate appropriateness criteria with practice guidelines, and we regret any confusion caused by our article.
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