A stated goal of the Patient Protection and Affordable Care Act (ACA), commonly referred to as “Obamacare,” is to improve the efficiency of American health care by curbing perceived cost inflation.1 The Act’s emphasis on decreasing costs and restructuring reimbursement models to reward quality, rather than quantity, of care has focused renewed attention on the appropriate use of cardiac interventions.
Clinical cardiac electrophysiologists, like other cardiologists, have faced scrutiny regarding the use of implantable cardioverter-defibrillator (ICD) devices and cardiac resynchronization therapy (CRT). A study by Al-Khatib et al found that nearly a quarter of all primary prevention ICDs were implanted for non-evidence-based indications.2 In tandem with a Department of Justice civil investigation into violations of the Centers for Medicare and Medicaid payment policy, these findings reinforced the need for rigorous methodology to validate ICD implantation.3
The American College of Cardiology Foundation (ACCF), in collaboration with the Heart Rhythm Society (HRS), have developed a series of appropriate use criteria (AUC) to assist clinical decision makers evaluating ICD placement and CRT for select patient populations.4 The AUC address 369 scenarios derived from real-life cases where ICDs and CRT are frequently considered, scored on a scale of 1 to 9 by panel. The scenarios are rated as either: “appropriate” (score of 7 to 9); “may be appropriate” (score of 4 to 6); or “rarely appropriate” (score 1 to 3). Utilization of the AUC is intended to “enhance physician decision making, healthcare delivery, and reimbursement policy” through a rigorous, systematic approach to device placement.5
For many different reasons, the busy clinician encounters several logistical obstacles to full implementation of the AUC in daily practice.6 The AUC guidelines cover the vast majority of cases encountered, yet identification of a specific patient’s clinical scenario may be challenging. The evidence supporting the panel ratings is not cited directly in the AUC guidelines, limiting clinician access to the original research. There is no open forum for medical professionals to discuss the ratings, a criticism that has been noted elsewhere.7 Lastly, despite the emphasis on electronic medical records (EMR) in the ACA, incorporation of AUC ratings in EMR can be awkward and cumbersome.
In order to address these shortcomings and to streamline the often-complicated ICD placement and CRT decision process, we present AUCMonkey.com. This is a suite of tools available as an app for the Apple iOS and Android operating systems, as well as an online website optimized for mobile access. AUCMonkey.com transforms the published ACCF and HRS guidelines into an extremely user-friendly format for immediate access. In addition, each decision is backed with a full complement of relevant studies and informative resources.
Included here are several images highlighting AUCMonkey.com features (Figures 1-4). Video 1 and video 2 illustrating the use of AUCMonkey.com are also included. In our first case, a patient with hypertrophic cardiomyopathy and recent unexplained syncope is evaluated for a primary prevention ICD. In our second case, a patient with hemodynamically unstable VT/VF due to giant cell myocarditis is evaluated for a secondary prevention ICD. In both cases we seek to demonstrate the smooth integration of guideline-based patient evaluation, accessibility of primary literature and references, as well as the ability to incorporate EMR and share cases through email.
Registration and subscription to AUCMonkey.com for two months is complimentary. We believe that the AUCMonkey.com toolkit will empower physicians, nurses, and electrophysiology laboratory technologists to utilize AUC in diverse settings such as clinical practice, basic and clinical research, quality assurance, and for educational purposes. Fellows-in-training, in particular, will benefit from enhancing their clinical decision making skills through regular use of AUCMonkey.com.
Disclosures: Drs. Hadadi and Dandamudi have no conflicts of interest to report regarding the content herein. Dr. Harjai is the CEO and co-founder of AUC Portal, LLC.
- Compilation of Patient Protection and Affordable Care Act. [As Amended Through November 1, 2010.] Including Patient Protection and Affordable Care Act Health-related Portions of the Health Care and Education Reconciliation Act of 2010. Published June 9, 2010. Available online at http://housedocs.house.gov/energycommerce/ppacacon.pdf. Accessed July 20, 2015.
- Al-Khatib SM, Hellkamp A, Curtis J, et al. Non-evidence-based ICD implantations in the United States. JAMA. 2011;305:43-49.
- Steinberg JS, Mittal S. The federal audit of implantable cardioverter-defibrillator implants: lessons learned. J Am Coll Cardiol. 2012 Apr 3;59(14):1270-1274.
- Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60(14):1297-1313. doi:10.1016/j.jacc.2012.07.009.
- Russo AM, Stainback RF, Bailey SR, et al. ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 appropriate use criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy: a report of the American College of Cardiology Foundation appropriate use criteria task force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2013 Mar 26;61(12):1318-68. doi: 10.1016/j.jacc.2012.12.017. Epub 2013 Mar 1.
- Harjai KJ, Sattur S. Appropriate Use Criteria in the Cath Lab: Can We Make Implementation Easier? Cath Lab Digest. Published May 2014. Available online at http://www.cathlabdigest.com/articles/Appropriate-Use-Criteria-Cath-Lab-Can-We-Make-Implementation-Easier. Accessed July 20, 2015.
- Marso SP, Teirstein PS, Kereiakes DJ, Moses J, Lasala J, Grantham JA. Percutaneous coronary intervention use in the United States: defining measures of appropriateness. JACC Cardiovasc Interv. 2012;5(2):229-235.