“The only problem is that the opposite of appropriate is inappropriate.”—Dr Spencer B King III

1. Appropriateness can be improved by Education (CME alone [very little effect] + printed material [small effect] + outreach with opinion leaders [additive effect] and Academic Detailing (Multi-factorial approach [somewhat effective] + professional societies [most effective]).
2. Guidelines are intended to inform clinicians when a diagnostic test or procedure should or should not be performed. They are evidence-based and synthesize published data to suggest what ‘can be done’ and what ‘must be done.’
3. Appropriate Use Criteria (AUC) are based on opinions. They delineate clinical scenarios of when ordering a test or procedure may be considered appropriate or less appropriate to be ordered and integrate the guidelines, clinical trial evidence, and quantify what we “should do”.
4. The potential impact of AUC is: Establishment of partnership among clinicians, educators, and payers regarding rational practices in CV imaging and fair reimbursement; education of clinicians regarding their practice habits; emphasis of clinical indications to drive testing; facilitate reimbursement for “appropriate”; support for requirement of preauthorization or denial of reimbursement for “rarely appropriate” indications; optimize CV care; improve cost-effectiveness.
5. To improve the selections, various models can be used such as placing the AUC tables in plain sight in each Cath lab; noninvasive cardiologists to review each case prospectively; obtaining inputs from “Heart Team”; and to have a proportion of randomly selected cases presented at a monthly conference on revascularization.