April 6, 2017
SNMMI has released a new appropriate use criteria (AUC) for bone scintigraphy in prostate and breast cancer, the two most common diagnoses for which bone scans are ordered in the adult population.
This is the first in a series of new AUC developed by SNMMI in its role as a qualified provider-led entity (PLE) under the Medicare Appropriate Use Criteria Program for advanced diagnostic imaging. These AUC are intended to assist referring physicians and ordering professionals to fulfill the requirements of the 2014 Protecting Access to Medicare Act (PAMA).
WHY IT’S IMPORTANT
Beginning January 1, 2018, all referring physicians or ordering professionals are required to consult appropriate use criteria using a clinical decision support mechanism before ordering any nuclear medicine study.
Going forward, reimbursement from CMS, as well as approval decisions for certain procedures by radiology benefits managers, is going to rely very heavily on the existence of AUC for the procedures. CMS is discussing a 5% penalty of outliers beginning in 2020.
WHAT SNMMI IS DOING
SNMMI is developing a comprehensive library of AUC for the most common nuclear medicine procedures. The society’s Guidance Oversight Committee (GOC) identified 10 high-priority areas for AUC development and release, beginning with the bone scan AUC (see What’s Next, below).
The process to develop AUC includes identification of relevant clinical scenarios, a systematic synthesis of available evidence, individual and group ratings of the scenarios using a formal consensus process, and document drafting based on final group ratings and discussions.
In accordance with the new process approved by CMS, each AUC expert workgroup selected to develop an SNMMI AUC has a minimum of 7 members, including (in addition to nuclear medicine subject matter experts) a primary care practitioner, an expert in clinical trial design, and an expert in statistical analyses. Other stakeholders, including patient representatives, industry experts, and members of other medical specialties are also consulted.
For the bone scintigraphy AUC, the workgroup was composed of representatives from SNMMI, the European Association of Nuclear Medicine (EANM), and the American Society of Clinical Oncology (ASCO).
In addition, SNMMI has contracted with the Oregon Health Science University's (OHSU) Evidence-based Practice Center to conduct independent and objective systematic reviews of relevant evidence to inform the AUC workgroups. The primary purpose of these systematic reviews is to assess the diagnostic accuracy and comparative effectiveness of selected nuclear medicine procedures in clinical decision making and clinical outcomes.
For a detailed explanation of this development process, click here.
SNMMI is currently developing nine additional AUC:
The GOC will conduct annual reviews of all AUC developed by SNMMI, evaluating the most recent medical literature to ensure that the AUC reflect current evidence. SNMMI is committed to the transparency of this process, and all AUC will be available to the general public and posted on the SNMMI website. New AUC will be published in The Journal of Nuclear Medicine’s Newsline and/or as complete articles in other sections of the journal.