We are writing in response to the recently published article by Rosenkrantz et al. . In the article, the authors point out that the Appropriateness Criteria (AC) of the American College of Radiology (ACR) provide guidance for many clinical concerns in the abdomen, but not for a majority of them, in the practice of a large urban academic medical center. We have been associated with the AC for a long time and wish to thank the authors of this article for their thoughtful and useful study and to provide some perspective. Although clearly not perfect, the AC, as the authors note, are the most complete and methodologically sound clinical imaging guidelines available. The process for creating, revising, and maintaining the AC is rigorous and time consuming and depends on the dedicated volunteer work of more than 1500 current and former panel members. Currently, there are more than 450 radiologists, radiation oncologists, and consultants from more than 20 other medical specialties, all volunteers, at work on the panels with important administrative support from the ACR. The AC were begun in 1993, to provide guidance as to which imaging test or tests, if any, would be most likely to be helpful in a specific clinical scenario. They were intended to provide both education and clinical guidance. Since 1996, the number of AC topics has nearly doubled (from 116 to over 200) and the number of variants has increased from 600 to over 980. New AC have been created to address scenarios that are important in terms of clinical impact, use of imaging, cost, and prevalence. The process of developing and revising each AC is well defined, comprehensive, and expensive. It is based on the RAND Corporation/University of California, Los Angeles Appropriateness Method User’s Manual . It begins with a systematic review of the published literature, including synthesis of the evidence and rating of the quality of the relevant peer-reviewed articles, followed by creation of a narrative addressing the topic, and then, with the use of the modified Delphi method, creation of a table of recommendations on the basis of benefits and harms. Topics are regularly updated, to ensure that they are based, to as great an extent as possible, on the most current, relevant literature. This rigorous methodology and the substantial time demands imposed by it of necessity limit the number of clinical problems that can be addressed.
It is, consequently, no surprise that, as the article points out, the ACR AC are not all inclusive. As Rosenkrantz et al. note, the AC cover only a limited number of staging and follow-up scenarios and do not deal extensively with incidental findings. This is intentional. The main focus of the AC is to address the role of imaging for patients presenting with specific symptoms or signs of disease. There is a separate committee within the ACR that is specifically dealing with incidental findings. Furthermore, attempting to cover all staging and follow-up indications is not possible because of resource constraints. Two indications outside of follow-up indications occupied the two highest frequency positions: screening for hepatocellular carcinoma and elevated Prostate Specific Antigen (PSA). We agree that hepatocellular carcinoma screening is a gap, and this is currently being addressed as one variant on a new topic on Chronic Liver Disease. The issue of elevated PSA as an indication for magnetic resonance imaging (MRI) is a controversial and evolving topic, and the answer is far from settled. There are clearly strong opinions about the role of MRI and a constant flow of publications, and we believe that this is an area that remains unsettled. Of necessity, the AC focus is on universally applicable utilization and topics where the literature is robust and reasonably conclusive. However, this issue highlights the need for clinical decision support tools that can be adopted for local practice, needs, and capabilities.
It is becoming widely recognized that there is a need for improved utilization of imaging and a growing consensus that this can be most efficiently addressed through the use of a comprehensive clinical decision support system, based on methodologically sound imaging guidelines. To this end, the ACR, in partnership with the National Decision Support Company (NDSC), has developed ACR Select as a tool that can be directly incorporated into electronic health records or be used independently and that can both provide guidance for and monitor the use of imaging. This tool is based on the AC and is substantially supplemented by many additional empiric clinical indications, with the intent to provide recommendations for the vast majority of clinical problems for which an imaging study might be considered. Importantly, ACR Select is modifiable to take into account local practice, equipment, and expertise, an important consideration as noted previously. ACR Select is still evolving, but we believe that it is already a comprehensive and robust clinical imaging decision-support system that will prove to be an important tool for improved use of imaging and improved patient care. We thank Rosenkrantz et al. for their efforts and will certainly share their results and insights with the relevant panels and with those, in the ACR and in NDSC, who are working on ACR Select.
References
1. Rosenkrantz A.B., Marie K., Doshi A.: Assessing the appropriateness of outpatient abdominopelvic CT and MRI examinations using the American College of Radiology Appropriateness Criteria. Academic Radiology 2014; E-pub ahead of print
2. Finch K., Bernstein S.J., Aguilar M.D., et. al.: RAND/UCLA Appropriateness Method User’s Manual.2001. Available at: http://www.rand.org/pubs/monograph_reports/MR1269.html Accessed October 2014