Appropriate Use Criteria
Current patterns of utilization of procedures are characterized by significant regional variation. Faced with uncertainties about the true nature of current utilization rates and patterns, clinicians, payers, and patients are demanding criteria to evaluate the "appropriateness" of cardiovascular services, especially for imaging. The American College of Cardiology Foundation (ACCF) believes that a careful blending of evidence-based information and clinical experience can help guide a more efficient and equitable allocation of health care resources. The ultimate objective of the criteria is to improve patient care and health outcomes in a cost-effective manner, without constraining the crucial role of physician judgment in the face of diverse clinical presentations and varying patient characteristics. Unlike comprehensive guidelines, appropriate use criteria focus on the most common patient scenarios for which procedures may be considered. The documents help define when it is reasonable to perform a procedure and importantly when it is not reasonable. The ACCF Appropriate Use Criteria Task Force oversees the creation of topic specific indications and appoints a technical panel per procedure considered. The panel utilizes a modified Delphi process to rate individual patient scenarios. Current scientific evidence is provided as one element for consideration during rating but cost, other tests, and physician judgment also are implicitly considered.
Clinical alerts are generally short (one- to two-page) scientific statements that are developed in response to a clinical issue that is time-sensitive and requires an immediate action. These most often evolve as the result of breaking news/science and are called to the ACCF’s attention through the Communications Department. They generally respond to new clinical information that requires clarification or interpretation of current policy. Clinical Alerts should not be confused with a Guideline Focused Update, which is initiated by the ACCF/American Heart Association (AHA) Task Force on Practice Guidelines as part of its biannual review of new evidence.
Competence and Training Statements
Competence and training statements present ACCF recommendations for the minimal education, training, and experience required to attain the cognitive and technical skills necessary for the competent performance of a specific cardiovascular procedure or technology. Training statements identify the education, training, and experience required for Levels 1, 2, and 3 expertise for fellowship training; competence statements focus on education, training and experience required for post-fellowship training. These documents are evidence-based to the extent possible and draw on the expert opinion of physicians in various practice settings to provide additional expertise. The development of competence and training statements is the domain of the ACCF/AHA/ACP Task Force on Competence and Training.
Note: The ACCF is NOT a licensing, credentialing, or certifying organization. ACCF recommendations regarding competence and training are developed to guide those individuals, institutions, and organizations responsible for cardiovascular training and certification programs.
The ACCF recognizes the importance of refining the lexicon used to describe the process and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality-improvement initiatives. Broad professional agreement on a common vocabulary with common definitions will facilitate cross-study comparisons or, when advantageous, combining of data across studies and will improve the assessment of any project's generalizability to clinical practice. Under the purview of the ACCF/AHA Task Force on Clinical Data Standards, the ACCF and AHA have undertaken the development and publication of clinical data standards, sets of standardized data elements and corresponding definitions that can be used in a variety of data collection efforts for a range of cardiovascular conditions. In addition to the expertise of the members of the ACCF/AHA Task Force on Clinical Data Standards and related writing committees, current scientific evidence, clinical trials, and national registries, provide the foundation for the selection and definition of data elements.
Expert Consensus Documents
Expert consensus documents are intended to inform practitioners, payers, and other interested parties of the opinion of the ACCF concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Expert consensus documents appear in the medical literature via publication in the Journal of the American College of Cardiology (JACC). These documents are evidence-based whenever possible but tend to be shorter than guidelines and developed around a topic that is more narrowly focused, that is new or emerging, and for which a smaller body of evidence is available. When appropriate, in lieu of convening a writing committee, a small consensus conference may be convened to bring together experts and generate a document. The ACCF Task Force on Clinical Expert Consensus Documents oversees the development of these documents.
Health Policy Statements
These documents generally promote or advocate the ACC's approach to health care policies and programs (e.g., pay for performance, retrospective review). Health Policy Statements are not intended to offer clinical guidance for treating patients, though periodically they focus on clinical topics. These statements are official ACC policy and are published in JACC or other journals as appropriate. These documents fall under the purview of the ACCF Clinical Quality Committee.
Clinical practice guidelines are developed through a rigorous methodological approach that mandates the review and consideration of the available medical literature. Practice guidelines define the role of specific diagnostic and therapeutic modalities, including noninvasive and invasive procedures, in the diagnosis and management of patients with various cardiovascular diseases. These evidence-based guidelines are intended to assist physicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. They attempt to define practices that meet the needs of most patients in most circumstances by categorizing the recommendations into a classification system. The development of clinical practice guidelines are the domain of the ACCF/AHA Task Force on Practice Guidelines and are published in JACC and Circulation.
The development of physician-level performance measures for important cardiovascular diseases and procedures is intended to promote the implementation of evidence-based guidelines. The intent of these measures is to provide practitioners with an opportunity to measure the quality of care for cardiovascular patients and to identify areas for further improvement. While these measures are based on and directly promote the use of ACCF/AHA clinical practice guidelines, it is important to note that they are not practice guidelines. Rather, they are specific measures that are indicative of quality, evidence-based care. As state and federal level efforts to measure quality and publicly report outcomes continue to expand, it is important that physicians be involved in every step of the process. As such, the ACCF, through the ACCF/AHA Task Force on Performance Measures, will continue to ensure that cardiovascular specialists play a central and guiding role in defining and measuring quality of care.
Consensus Conference Reports: Consensus conferences are designed to facilitate consideration of significant and timely issues regarding the practice of cardiovascular medicine and matters affecting patient care, research, and training for which data are incomplete. Appropriate organizations other than the ACC/ACCF are invited to send representatives to participate in the process. These may include physicians and health care specialists as well as representatives from industry, government, foundations, and the public sector. A report is published to highlight recommendations, along with dissenting opinion, if appropriate. Consensus Conference Reports generally evolve as conference proceedings They include a disclaimer that the recommendations in the report are those of the Conference participants and do not necessarily reflect the official position of the ACCF. Consensus conference reports fall under the purview of the ACCF Task Force on Clinical Expert Consensus Documents.
Survey and Data Reports: Survey reports are developed by an ACC or ACCF Committee for the sole purpose of presenting data and/or scientific research evolving from a Committee initiative. The articles undergo a modified peer review process, including the groups that sponsored the articles, and are published in JACC. The articles represent the views of the writers and carry the caveat that the findings and conclusions in the report are those of the writing committee and do not necessarily reflect the official position of the ACCF.