RSNA: Appropriate use guidelines may not be ready for prime time

CHICAGO—Appropriate use criteria present viable checks to "unfettered" and "unsustainable" growth in healthcare costs; yet guidelines remain considerably unimplemented because of questionable evidence and varying qualities, according to a Nov. 29 presentation at the 96th annual scientific meeting of the Radiological Society of North America (RSNA).

Citing decades of varying quality, spiking imaging costs and the more than 2,700 sets of clinical guidelines for healthcare listed on the National Guideline Clearinghouse, broader implementation of appropriateness criteria demands more transparent, evidence-based standards, argued Earl Steinberg, MD, of Johns Hopkins University School of Medicine in Baltimore, Md.

Steinberg enumerated four principal concerns with presently available appropriate use criteria:
• Eminence too often takes precedence over strong evidence in the development of appropriate use guidelines.
• An overwhelming volume of clinical studies, many with complex and questionable methodologies and conclusions, yield guidelines of varying qualities.
• Appropriate use criteria commonly contradict each other, leaving time-strapped referring physicians and radiologists unable to evaluate the preponderance of clinical studies and therefore without appropriate guidance in determining the quality of criteria.
• Conflicts of interest and biases constitute persistent problems embedded not only in clinical studies but also in associations' clinical guidelines, most of which call for higher exam volumes for their own specialties.

Steinberg argued that these methodological faults in appropriate use criteria, including those of the American College of Radiology (ACR), lead to poor adoption of guidelines and therefore subpar patient care. The presenter recommended that the development of guidelines, particularly the ACR's Appropriateness Criteria, incorporate the Institute of Medicine's (IOM) recommendations:
• Objectivity throughout the process;
• External review of the proposed guidelines;
• Monitoring and updating of guidelines based on clinical outcomes;
• Transparency throughout the development of the appropriateness criteria; and
• Positive efforts to increase consensus on the guidelines.

In addition, Steinberg highlighted the importance of explaining the strength of evidence for procedures as well as rationales for deviating from the criteria, which would make decision-support more specific.

Overall, Steinberg argued for increased scrutiny and revision of appropriate use guidelines, with the aim of facilitating rather than slowing their implementation and effects on clinical practice.