2012 Criteria for Peripheral Vascular Ultrasound Part I
2012 Criteria for Peripheral Vascular Ultrasound Part I
The indications included in this publication cover a wide array of cardiovascular signs and symptoms as well as clinical judgments as to the likelihood of cardiovascular findings. Within each main disease category, a standardized approach was used to capture the majority of clinical scenarios without making the list of indications excessive.
The indications were constructed by experts in peripheral vascular disease and in other fields and were modified on the basis of discussions among the task force and feedback from independent reviewers and the technical panel. Wherever possible, indications were mapped to relevant clinical guidelines and key publications/references where available in the medical literature (Online Appendix).
A detailed description of the methods used for ranking the selected clinical indications is found in a previous publication, "ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging". Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise.
The technical panel first rated indications independently. Then, the panel was convened for a face-to-face meeting for discussion of each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers' scores. After the meeting, panel members were then asked to independently provide their final scores for each indication.
Although panel members were not provided explicit cost information to help determine their appropriate use ratings, they were asked to implicitly consider cost as an additional factor in their evaluation of appropriate use. In rating these criteria, the technical panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate, and was provided the following definition of appropriate use:
An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequence* by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.
The technical panel scored each indication as follows:
Median Score 7 to 9
Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).
Median Score 4 to 6
Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.
Median Score 1 to 3
Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).
The division of these scores into 3 levels of appropriateness is somewhat arbitrary, and the numeric designations should be viewed as a continuum. Further, there is diversity in clinical opinion for particular clinical scenarios, such that scores in the intermediate level of appropriate use should be labeled "uncertain," as critical patient or research data may be lacking or discordant. This designation should be a prompt to the field to carry out definitive research investigations whenever possible. It is anticipated that the AUC reports will continue to be revised as further data are generated and information from the implementation of the criteria is accumulated.
To prevent bias in the scoring process, the technical panel was deliberately comprised of a minority of specialists in vascular noninvasive testing. Specialists, although offering important clinical and technical insights, might have a natural tendency to rate the indications within their specialty as more appropriate than nonspecialists. In addition, care was taken in providing objective, nonbiased information, including guidelines and key references, to the technical panel.
The level of agreement among panelists as defined by RAND was analyzed based on the BIOMED rule for a panel of 14 to 16 members. As such, agreement was defined as an indication where 4 or fewer panelists' ratings fell outside the 3-point region containing the median score.
Disagreement was defined as where at least 5 panelists' ratings fell in both the appropriate and the inappropriate categories. Any indication having disagreement was categorized as uncertain regardless of the final median score. Indications that met neither definition for agreement or disagreement are in a third, unlabeled category.
Methods
The indications included in this publication cover a wide array of cardiovascular signs and symptoms as well as clinical judgments as to the likelihood of cardiovascular findings. Within each main disease category, a standardized approach was used to capture the majority of clinical scenarios without making the list of indications excessive.
The indications were constructed by experts in peripheral vascular disease and in other fields and were modified on the basis of discussions among the task force and feedback from independent reviewers and the technical panel. Wherever possible, indications were mapped to relevant clinical guidelines and key publications/references where available in the medical literature (Online Appendix).
A detailed description of the methods used for ranking the selected clinical indications is found in a previous publication, "ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging". Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise.
The technical panel first rated indications independently. Then, the panel was convened for a face-to-face meeting for discussion of each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers' scores. After the meeting, panel members were then asked to independently provide their final scores for each indication.
Although panel members were not provided explicit cost information to help determine their appropriate use ratings, they were asked to implicitly consider cost as an additional factor in their evaluation of appropriate use. In rating these criteria, the technical panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate, and was provided the following definition of appropriate use:
An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequence* by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.
The technical panel scored each indication as follows:
Median Score 7 to 9
Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).
Median Score 4 to 6
Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.
Median Score 1 to 3
Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).
The division of these scores into 3 levels of appropriateness is somewhat arbitrary, and the numeric designations should be viewed as a continuum. Further, there is diversity in clinical opinion for particular clinical scenarios, such that scores in the intermediate level of appropriate use should be labeled "uncertain," as critical patient or research data may be lacking or discordant. This designation should be a prompt to the field to carry out definitive research investigations whenever possible. It is anticipated that the AUC reports will continue to be revised as further data are generated and information from the implementation of the criteria is accumulated.
To prevent bias in the scoring process, the technical panel was deliberately comprised of a minority of specialists in vascular noninvasive testing. Specialists, although offering important clinical and technical insights, might have a natural tendency to rate the indications within their specialty as more appropriate than nonspecialists. In addition, care was taken in providing objective, nonbiased information, including guidelines and key references, to the technical panel.
The level of agreement among panelists as defined by RAND was analyzed based on the BIOMED rule for a panel of 14 to 16 members. As such, agreement was defined as an indication where 4 or fewer panelists' ratings fell outside the 3-point region containing the median score.
Disagreement was defined as where at least 5 panelists' ratings fell in both the appropriate and the inappropriate categories. Any indication having disagreement was categorized as uncertain regardless of the final median score. Indications that met neither definition for agreement or disagreement are in a third, unlabeled category.
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