According to Kristy L. Weber, MD, past chair of the AAOS Council on Research and Quality, “Appropriate Use Criteria (AUC) specify when it’s appropriate to perform a procedure or service.” An “appropriate” procedure is one for which the expected health benefits exceed the expected health risks by a wide margin.

AUC are a response to the dilemma faced by physicians every day. They must decide when to use a procedure or service, even though high-level evidence or sufficiently detailed data are often not available. AUCs facilitate these decisions by combining the best available scientific evidence with the collective judgment of physicians to determine the appropriateness of performing a procedure.

The difference between evidence-based clinical practice guidelines (CPGs) and AUC, Dr. Weber told attendees at the 2012 National Orthopaedic Leadership Conference is that “Evidence-based CPGs tell us if a procedure or service works. AUC specify when it’s appropriate to perform that procedure or service. Neither CPGs nor AUC ask who should do the procedure, but AUC ask on whom it should be done.”

Dr. Weber noted that AUC are not consensus documents, but are based on systematic reviews and CPGs, if they are available. The AAOS has developed a “top 10” list of AUC, which it plans to develop. (See “Orthopaedic AUC Topics,” this page.) The list is based on the existence of current CPGs in each of the areas, which provide the evidence background. Dr. Weber cautioned, however, that “AUC are not substitutes for CPGs that you don’t like, nor are they substitutes for sound clinical judgment and practice experience.”

AUC development
The development of AUC relies on three panels—a writing group, a review group, and a technical rating group. Members of the writing group—all of whom would be orthopaedic surgeons or those who perform the procedure—develop a set of scenarios that describe patients who might have the condition. The scenarios include patient symptoms, medical history, test results, and imaging. Up to 100 clinical scenarios for each condition may be developed.

The scenarios are then sent to the members of the review group, who are also primarily orthopaedic surgeons. This group reviews all the scenarios to ensure that they represent realistic patients and treatment decisions that practitioners are likely to encounter.

The final group is the technical rating panel, which reviews the acceptable scenarios and ranks each based on the following scale:

7–9: Appropriate test/procedure for specific indication—The test/procedure is generally acceptable and is a reasonable approach for the indication.

4–6: Uncertain or unclear if the test/procedure is appropriate for specific indication—The test may be generally acceptable and may be a reasonable approach for the indication.

1–3: Inappropriate test/procedure for specific indication—Test/procedure is not generally acceptable and is not a reasonable approach for the indication.

The members of the technical rating panel meet in person, and more than half of the panel members will be individuals who do not generally perform the test or procedure such as general or other specialty surgeons, family practice physicians, and payers. This is done to balance the review and ensure that the indications are clearly understood.

The AAOS role
“Appropriate Use Criteria give the AAOS the opportunity to participate in healthcare reform,” said Dr. Weber. “They help ensure the highest quality of care for patients undergoing musculoskeletal procedures.

“AUCs,” she continued, “are an example of best practices and indications for treating patients safely and cost-effectively. They take CPGs one step farther, by broadening their findings and stratifying risk.”

The AAOS plans to work with payers, such as the Centers for Medicare & Medicaid Services, to enhance quality and improve the cost-effectiveness of orthopaedic services. “AAOS members—orthopaedic specialists—are key to this development,” said Dr. Weber.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Orthopaedic AUC Topics

• Treatment of Distal Radius Fractures
• Rotator Cuff Management
• Knee Arthroscopy
• Imaging for Shoulder Pain
• Operative Treatment of Hip Fractures
• Total Knee Replacement
• Imaging for Knee pain
• Imaging for Low Back Pain
• Lumbar Fusion for Low Back Pain
• Total Hip Replacement