Rationale and Objectives
To retrospectively assess the appropriateness of outpatient abdominal and pelvic computed tomography (CT) and magnetic resonance imaging (MRI) examinations using the American College of Radiology Appropriateness Criteria (AC).
Materials and Methods
A total of 570 adult outpatient abdominopelvic CT (304) and MRI (266) studies performed in a 1-month period with available documentation of the clinical encounter generating the imaging order were included. On the basis of review of the imaging report and patient record, examinations were classified in terms of match to a specific AC variant, appropriateness score, and the presence of a significant result. Data were analyzed using Fisher’s exact test.
Results
Forty-five percent of examinations matched an AC variant: 52% of CT and 38% of MRI ( P < .001). Ninety-two percent of examinations matching the AC were appropriate: 96% of CT and 86% of MRI ( P = .009). Appropriate examinations were more likely to provide a significant result than not appropriate studies (48% vs. 24%, P = .041). Although a significant result was related to the primary study indication more frequently in appropriate than not appropriate examinations, this difference was not significant (93% vs. 80%, respectively, P = .204). The most common indications not matching an AC were colon cancer follow-up ( n = 14) and melanoma follow-up ( n = 14) among CT, and hepatocellular carcinoma screening ( n = 31) and elevated prostate-specific antigen (PSA) without prior biopsy ( n = 14) among MRI.
Conclusions
Most examinations matching the AC were appropriate, and appropriate examinations were more likely to have a significant result. However, most examinations, including 62% of MRI, had no relevant clinical condition, highlighting a critical area for future AC expansion and modification.
In response to concerns of escalating use of imaging services and wide variability in such use, the American College of Radiology (ACR) launched an initiative in 1993 to formulate guidelines to assist in appropriate ordering of imaging studies . The resulting ACR Appropriateness Criteria (AC) seek to standardize which imaging examinations are ordered for a wide array of clinical conditions and thereby reduce variation and overutilization . The AC strive to optimize the balance between benefit and risk inherent to imaging examinations by maximizing diagnostic yield and provision of useful information in consideration of the examination’s costs, radiation exposure, other procedural risks, and possibility of incidental findings . The AC were crafted by multidisciplinary expert panels in an evidence-based fashion using a modified Delphi approach . AC are organized in terms of specific clinical conditions and associated variants, ranking for each variant the appropriateness of relevant imaging examinations on a 1–9 scale; a score of 7–9 indicates that the given imaging examination is “usually appropriate” for the given condition . From the time of their introduction, the AC have been continually expanded and updated by the ACR , and currently AC exist for over 197 clinical conditions with over 900 variants .
The AC are the only guidelines in the United States to direct the ordering of diagnostic imaging examinations for a comprehensive spectrum of clinical scenarios, as reflected by the large number of conditions and variants addressed . In comparison, other available guidelines, such as the National Comprehensive Cancer Network and American Society of Clinical Oncology guidelines, generally direct imaging examinations in limited contexts, such as cancer staging and post-treatment surveillance. The AC have been applied for numerous purposes, such as by private insurers for directing patient benefit policies , by academic institutions as the basis for the development of clinical decision support systems , and by radiologists as a basis of educating other physicians in appropriate examination ordering . More recently, the “Protecting Access to Medicare Act of 2014” Act (H.R. 4302, signed into law April 1, 2014) requires that health care providers consult appropriateness use criteria endorsed by national professional medical societies when ordering imaging services . It is expected that the ACR AC will be a primary set of guidelines used in fulfilling this requirement . This legislation enhances the potential impact of the ACR AC given the large influence of Medicare policy on medical practice in the United States. Thus, as the legislation undergoes implementation, it is important to recognize any limitations or weaknesses of the ACR AC. However, only a small amount of the literature has assessed the overall level of appropriateness of diagnostic imaging examinations relative to the ACR AC or the association of such appropriateness with outcomes . Such knowledge would be useful in guiding continued policy development. Therefore, we conducted this study to evaluate the appropriateness of outpatient abdominal and pelvic computed tomography (CT) and magnetic resonance imaging (MRI) examinations using the ACR AC, as well as associations between appropriateness and imaging results.
Methods
Selection of Imaging Examinations
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Imaging Examination Review
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Statistical Assessment
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Results
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Table 1
Most Common Indications of Computed Tomography Examinations not Matching an Appropriateness Criteria Variant ∗
Indication_n_ Colon cancer follow-up 14 Melanoma follow-up 13 Weight loss; no abdominal pain 9 Abdominal pain not localized to one quadrant; no fever, recent surgery, or laboratory abnormality 8 Lymphoma follow-up 7 Pancreatic cancer follow-up 7 Weight loss and abdominal pain not localized to one quadrant 6 Hepatocellular carcinoma screening 3 Anemia 3 Lung cancer follow-up 3 Breast cancer follow-up, not stage I 3 Neuroendocrine tumor follow-up 3
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Table 2
Most Common Indications of Magnetic Resonance Imaging Examinations not Matching an Appropriateness Criteria Variant ∗
Indication_n_ Hepatocellular carcinoma screening 31 Elevated PSA, no prior prostate biopsy 14 Hepatocellular carcinoma follow-up 11 Solid renal mass, surveillance 9 Lower extremity edema/ulcer, concern for iliac vein compression 9 Fibroids, pretreatment planning; no acute pelvic pain 8 Ureteropelvic junction (UPJ) obstruction 5 Elevated PSA, one prior negative prostate biopsy 5 Pancreatic cyst follow-up 5 Tuberous sclerosis; screening for renal mass 4
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Table 3
Classification of Imaging Examinations Using the ACR AC
Characteristic Entire Cohort CT MRI_P_ ∗ Match ACR AC † 45% (258/570) 52% (158/304) 38% (100/266) <.001 Appropriate examination ‡ 92% (237/258) 96% (151/158) 86% (86/100) .009
AC, Appropriateness Criteria; ACR, American College of Radiology; CT, computed tomography; MRI, magnetic resonance imaging.
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Table 4
Association Between Imaging Examination Appropriateness and Examination Results
Characteristic Appropriate Examinations Not Appropriate Examinations_P_ Significant result 48% (113/237) 24% (5/21) .041 Related to indication ∗ 93% (105/113) 80% (4/5) .204
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Discussion
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Conclusions
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