{"id":16099,"date":"2012-02-16T15:20:57","date_gmt":"2012-02-16T20:20:57","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=expert-is-in&p=16099"},"modified":"2012-02-16T15:30:49","modified_gmt":"2012-02-16T20:30:49","slug":"part-2-clashing-views-of-appropriate-use-criteria-for-pci","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/02\/16\/part-2-clashing-views-of-appropriate-use-criteria-for-pci\/","title":{"rendered":"Part 2: Clashing Views of Appropriate Use Criteria for PCI"},"content":{"rendered":"

In\u00a0a recent Viewpoint in JACC: Cardiovascular Interventions<\/a>,\u00a0Marso\u00a0and colleagues\u00a0expressed grave reservations about the application of appropriate use criteria for PCI in a\u00a0controversial study published last year in JAMA<\/a>\u00a0by Chan\u00a0and colleagues,\u00a0which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors\u00a0Rick Lange and David Hillis asked CardioExchange members for their opinions<\/a>\u00a0on this topic. In this series of posts, Lange and Hillis question the main protagonists in the debate,\u00a0Steven Marso<\/strong>\u00a0and\u00a0Aaron Grantham<\/strong>, on the one side, and\u00a0Paul Chan<\/strong>\u00a0and\u00a0John Spertus<\/strong>\u00a0on the other side. All the authors are affiliated with the\u00a0Saint Luke’s Mid America Heart Institute in Kansas City, Missouri. Click here<\/a> for Part 1.<\/em><\/p>\n

Lange & Hillis:\u00a0<\/strong>The writing group and technical panel for the 2009 AUC and the 2012 update were almost identical (only\u00a01 exception), and only\u00a0four interventional cardiologists participated in the writing group. Should more (or different) interventional cardiologists be involved in the AUC process?<\/strong><\/em><\/p>\n

Chan & Spertus:\u00a0<\/strong>We believe that\u00a0the inclusion\u00a0of\u00a0a broad range of perspectives in adjudicating the strength of revascularization appropriateness is an asset\u00a0\u2014 particularly because the evidence of benefit should be transparent to all physicians (interventionalists and noninvasive cardiologists alike) caring for CAD patients. In fact, 12 of the 17 panel members are practicing cardiologists who either refer patients for or perform PCI. This is important because the responsibility for a potentially inappropriate PCI should be shared not only\u00a0by interventionalists performing the procedure, but also by referring physicians.<\/p>\n

Contrary\u00a0to the assertion of Marso and colleagues,\u00a0the\u00a0ratings of 85 practicing cardiologists in our paper in JACC<\/em> correlated exceedingly well with the expert panel, especially given that the latter were able to meet face-to-face to resolve differences of opinion. The interventional members of the AUC technical panel were recommended by SCAI and ACC, and we believe that they should have represented the mainstream perspective of that community; furthermore,\u00a0the iterative process of determining AUC ratings within the expert panel gave the interventionalist members the opportunity to persuade the rest of the panel if there were indeed compelling data and experiences that should have swayed the appropriateness ratings.<\/p>\n

Marso & Grantham:<\/strong>\u00a0We feel strongly there needs to be broader inclusion of interventional cardiologists in the AUC process. Four is just not enough. We acknowledge that the ACCs current methodology purposefully limits the absolute number of specialty-specific experts involved in the technical panel when creating appropriate use criteria. However, we believe the process would be improved with better representation from interventional cardiologists. Perhaps a way to accomplish this would be for the AUC technical committee to commission a working group of interventional cardiologists to provide direct feedback to the AUC Technical Committee. Certainly, the FDA uses advisory panels when considering drug or device approval decisions. We believe this would be a feasible strategy to broaden participation while\u00a0limiting the Technical Panel to the RAND criteria. Perhaps it is also time for the ACC to review the rationale for using RAND methodology in establishing AUC documents. The RAND methodology has been around since the 1950s. It is certainly commonly employed in many complex decision-making situations. One wonders, has RAND methodology been consistent and successful in changing physician behavior over the years? Is this the best methodology for the ACC to employ moving forward? To those of us non-RAND experts, it does seem to be rather exclusionary, and its decision-making process less than transparent to outsiders.<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

In\u00a0a recent Viewpoint in JACC: Cardiovascular Interventions,\u00a0Marso\u00a0and colleagues\u00a0expressed grave reservations about the application of appropriate use criteria for PCI in a\u00a0controversial study published last year in JAMA\u00a0by Chan\u00a0and colleagues,\u00a0which found that only half of PCIs performed for nonacute indications were classified as appropriate. Interventional cardiology editors\u00a0Rick Lange and David Hillis asked CardioExchange members for their […]<\/p>\n","protected":false},"author":565,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,9],"tags":[1134,301],"class_list":["post-16099","post","type-post","status-publish","format-standard","hentry","category-general","category-interventional-cardiology","tag-appropriate-use-criteria","tag-pci"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/16099","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/565"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=16099"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/16099\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=16099"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=16099"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=16099"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}