We thank Drs. Yucel and Bettman for their interest in our article and for the further commentary regarding the American College of Radiology (ACR) Appropriateness Criteria (AC) that they provide in their letter. These authors have been instrumental in the development of the ACR AC and are well positioned to provide these additional insights regarding the background, development, and current status of the ACR AC. We anticipate that readers interested in our original article will also find interest in this additional perspective that has been provided for the ACR AC. We agree with Drs. Yucel and Bettman regarding the importance of providing evidence-based clinical decision support to guide appropriate imaging utilization for specific clinical scenarios. Additionally, we appreciate the enormous time and resources devoted by the ACR and its many volunteers in development of the AC, as described by the authors.
Drs. Yucel and Bettman express concern regarding our study’s observation of a substantial fraction of outpatient computed tomography and magnetic resonance imaging examinations performed at our institution not matching any clinical condition or variant within the ACR AC. We note that our primary aim was to evaluate the appropriateness of examinations that did match an ACR AC. In this respect, our findings are indeed favorable toward the ACR AC. The overwhelming majority of examinations matching the ACR AC were considered appropriate on the basis of the criteria, and appropriate examinations were more likely to yield a significant result than nonappropriate examinations. The observed large frequency of examinations not matching an ACR AC variant is not a unique finding to our study. For example, past studies by Martin et al. and Levy et al. also reported a substantial fraction of examinations in their analyses without a match. The explanation provided by Drs. Yucel and Bettman regarding the intentional nature of the limited scope of the ACR AC is helpful to provide context for such findings, and it is reassuring to know of the ongoing efforts to continually expand the number of clinical conditions covered.
Drs. Yucel and Bettman also note the recent availability of ACR Select, developed in partnership by the ACR and the National Decision Support Company (NDSC), which supplements the ACR AC with guidelines developed in an empiric and more efficient manner to cover a much larger array of clinical conditions warranting imaging, thereby providing a more comprehensive decision support tool. We applaud the ACR and NDSC for development of this greatly expanded system and strongly agree that ACR Select can contribute to both improved utilization and improved patient care. Nonetheless, we believe that investigation and understanding of current gaps in coverage of the ACR AC is important, acknowledging the more complete nature of ACR Select. The ACR AC are made freely available on the ACR web site and are taken into consideration by many practices throughout the United States. In comparison, ACR Select is a commercial product requiring an upfront financial investment and, according to information provided on the NDSC web site at the time of this writing , has so far been adopted by fewer than 100 health care organizations nationally. Although we acknowledge a recent surge of interest in ACR Select and that its utilization is anticipated to greatly increase in the near future, partly related to measures contained within the Protecting Access to Medicare Act of 2014 , the ACR AC are the primary tool for directing the ordering of diagnostic imaging examinations in clinical usage at the present time. In addition, depending on the context, the ACR AC may be deemed the more relevant reference standard for evaluating imaging utilization given the much more rigorous process involved and level of evidence required in their development. Finally, identification of specific commonly ordered imaging examinations that do not match the ACR AC, as reported in our study, is useful for directing further development and expansion of ACR Select, which Drs. Yucel and Bettman acknowledge in their letter.
In conclusion, we thank Drs. Yucel and Bettman for their interest in our article. We appreciate their comment that they will share insights from our work with the relevant panels in the ACR and NDSC. Likewise, we will take the insights provided in their letter into consideration for our own future investigations regarding imaging utilization. We fully agree with the value of clinical decision support in imaging utilization and appreciate the extensive efforts of the ACR and NDSC in this regard and look forward to the continued evolution and clinical adoption of these tools.
References
1. Martin T.A., Quiroz F.A., Rand S.D., et. al.: Applicability of American College of Radiology appropriateness criteria in a general internal medicine clinic. AJR. American Journal of Roentgenology 1999; 173: pp. 9-11.
2. Levy G., Blachar A., Goldstein L., et. al.: Nonradiologist utilization of American College of Radiology Appropriateness Criteria in a preauthorization center for MRI requests: applicability and effects. AJR. American Journal of Roentgenology 2006; 187: pp. 855-858.
3. American College of Radiology. “ACR Appropriateness Criteria®.” http://www.acr.org/quality-safety/appropriateness-criteria . Accessed April 7, 2014.
4. National Decision Support Company. News. http://www.acrselect.org/news.html . Accessed November 6, 2014.
5. United States Government Printing Office. H.R. 4302: Protecting Access to Medicare Act of 2014. http://www.gpo.gov/fdsys/pkg/BILLS-113hr4302enr/pdf/BILLS-113hr4302enr.pdf . Accessed April 7, 2014.