How Appropriate Are Appropriate-use Criteria?

In their paper titled “Appropriateness and Total Hip Arthroplasty: Determining the Structure of the American Academy of Orthopaedic Surgeons System of Classification,” Riddle and Perera have analyzed the American Association of Orthopedic Surgeons (AAOS) appropriate-use criteria (AUC) for total hip arthroplasty (THA)1. They aimed to determine the contribution of each of the variables included by the AAOS (age, function-limiting pain, hip radiographic evaluation, range-of-motion limitation, presence or absence of modifiable risk factors) to the classification of appropriateness. An appropriate procedure is commonly defined as one for which “the expected health benefits significantly exceed the expected health risks by a wide margin,” based on the best available evidence2. The aim of AUC is to improve patient care and outcomes, and to identify the complexities of clinical decision making, helping practitioners and patients make a decision about a specific procedure in a specific clinical condition. The US Center for Medicare and Medicaid Services (CMS) established a program to promote AUC in response to both overuse and underuse of medical procedures, and to link them to physician payments (now pushed back to 2020). In response to the CMS and cognizant of wide regional variations in the use of arthroplasty, the significant proportion of recipients who are dissatisfied, and the expenditure of billions of dollars annually, the AAOS developed AUC to guide management of osteoarthritis of the hip, including performance of THA3. Appropriateness differs from guideline recommendations, which provide overarching approaches to healthcare but cannot determine whether the procedure should be performed in an individual patient’s situation. This is where AUC can be used for guidance in decision making, because AUC can identify gradations in severity of disease or risk in specific clinical situations. In a process using the RAND/University of California at Los Angeles Appropriateness Method, the … Address correspondence to Dr. S.M. Goodman, Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St., New York, New York 10021, USA. E-mail: goodmans{at}hss.edu.

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