Awareness, Utilization, and Education of the ACR Appropriateness Criteria: A Review and Future Directions

Purpose: With the overall rise in the use of medical imaging over the past two decades, overutilization has become a major concern. The ACR Appropriateness Criteria (AC) are an evidence-based, web-based, peer-reviewed resource designed to assist clinicians in making the most appropriate imaging decisions. In this literature review, the authors assess the current knowledge, utilization, and education of the AC among undergraduate and graduate medical education trainees and practicing physicians in both radiologic and nonradiologic specialties. Methods: A comprehensive literature search was completed using the PubMed, Cochrane, and MedEdPORTAL databases with the query American College of Radiology Appropriateness Criteria. Articles written in English and published from 1993, the year when the AC were introduced, to present were included for review. Retrieved articles were reviewed for relevance. Results: The published literature is sparse. A review suggests a low rate of incorporation of the AC into clinical practice. Formal training in appropriate imaging ordering practices in both undergraduate and graduate medical education is lacking. The several studies targeting the use of the AC demonstrate that educational interventions increase awareness of the criteria as a decision tool. Conclusions: The low rate of incorporation of the AC into clinical practice may reflect the lack of formal training in appropriate imaging order practices, specifically in the use of the AC, in both undergraduate and graduate medical education. The integration of the AC into decision support may reduce overutilization, but this has not been fully studied. Greater integration of the AC into medical training would require more universal physician buy-in to use the AC as a resource to optimize imaging utilization. This further requires sustained efforts to improve the user-friendliness of the AC and maximization of collaboration with nonradiology specialties in the development of the AC.