The Importance of ACR Appropriateness Criteria

Third-year clinical rotations are an eye-opening experience for medical students interested in radiology. Throughout these rotations, I had the opportunity to see what it’s like to interact with the radiology department through the lens of different specialties. This was a tremendous learning experience, allowing me to understand what clinicians from various departments, such as pediatrics, surgery and internal medicine, expect and look for when ordering radiological tests. 

Most importantly, I gained a deeper appreciation for the key role that radiologists play across the entire field of medicine.

During my visits to reading rooms on behalf of residents in my clinical rotations, I became aware of a common frustration among radiologists — namely, the indiscriminate ordering of imaging studies. In addition, physicians were often ordering studies not indicated by their own specialty’s professional association guidelines.

On one particular day, as part of a case report assignment during one of my clinical rotations, I had to discuss a radiological image with a radiology attending for a patient I had interviewed in the emergency room. The patient was suspected of having a transient ischemic attack after an episode of unilateral extremity weakness. The attending radiologist was surprised when he realized that the referring institution had ignored the stroke protocol, prioritizing a chest X-ray over a head CT.

To address this issue, the ACR® provides imaging guidelines such as the ACR Appropriateness Criteria®. These guidelines are an invaluable resource not only for radiologists and radiology-inclined medical students but for every physician and medical student, regardless of their specialty or career interests.

The ACR Appropriateness Criteria offer evidence-based guidelines for selecting the most appropriate imaging studies for a wide range of clinical conditions. The ACR has adopted the definition of “appropriateness” from the RAND/UCLA Appropriateness Method User’s Manual, which defines an appropriate procedure as one in which the expected health benefits exceed the expected negative consequences by a sufficiently wide margin to justify its use.

With more than 247 documents covering diagnostic imaging and interventional radiology, the ACR Appropriateness Criteria include more than 4,000 clinical scenarios to guide physicians in their decisionmaking. They not only help ensure that patients receive the most appropriate imaging studies but also prioritize patient safety and aim to reduce unnecessary imaging. Each recommendation is supported by a robust review of the medical literature, giving physicians the confidence that their imaging choices are both clinically and cost-effective.

Unfortunately, logistical challenges have hindered the widespread implementation of the ACR Appropriateness Criteria. In response to a recent U.S. Senate hearing, the ACR submitted a statement supporting the Protecting Access to Medicare Act of 2014 (PAMA). PAMA requires physicians to consult physician-developed appropriate use criteria (AUC) when ordering advanced imaging for Part B Medicare patients to improve accuracy and reduce unnecessary scans. 

The ACR statement highlights clinician use of AUC has shown improvements in appropriate image ordering and cost savings for institutions and patients. Despite Congress mandating implementation by 2017 and Medicare estimating $700 million in annual savings, the program was paused in 2024. ACR is working with lawmakers to restart the program, emphasizing its benefits. 

Recognizing the importance of appropriate imaging, I highly recommend that all medical students, regardless of their specialty inclination, complete the course, Introduction to Appropriateness Criteria — Medical Student Education. Doing so will not only enable you to communicate effectively with radiologists, but you can also impress your attendings along the way. More importantly, it will ensure that you provide your patients with the most appropriate diagnostic imaging, improving their clinical outcomes and minimizing unnecessary radiation exposure