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Appropriateness Criteria

Variant 1: Chronic extremity joint pain. Suspect inflammatory (seropositive or seronegative arthritis), crystalline (gout or pseudogout), or erosive osteoarthritis. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography area of interest Usually appropriate Strong Varies Varies 9 9 0 0 0 0 0 0 0 2 14
References Study Quality
13 (23520036) 4
12 (11145034) 1
11 (16848914) 2
10 (21278073) M
9 (10366117) 1
8 (24450681) 3
US area of interest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 2 0 0 0 1 1 0
MRI area of interest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 1 1 0 0 0
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 2 0 2 0 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 15 1 0 0 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 16 0 0 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 2 0 1 0 0 0 0
Variant 2: Chronic extremity joint pain. Suspect inflammatory arthritis (seropositive or seronegative arthritis). Radiographs normal or inconclusive. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 1 3 1 1 9
References Study Quality
46 (32803573) 4
45 (27219303) 1
44 (23997769) 3
43 (19714611) 2
42 (24488415) 2
41 (23553120) 3
40 (33556758) 2
39 (33180165) 2
38 (15077292) 1
37 (31630207) 3
36 (31304659) 3
35 (28340066) Not Assessed
34 (24356473) 3
33 (26939710) 3
32 (32211929) 4
31 (31663417) 3
30 (24445255) 2
29 (21538312) 2
25 (23192434) 4
21 (22723498) 2
18 (24528508) 4
13 (23520036) 4
12 (11145034) 1
11 (16848914) 2
MRI area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 3 11
References Study Quality
28 (25537977) 3
24 (20966327) 4
25 (23192434) 4
27 (29490980) 1
26 (30770509) 3
23 (25636414) 3
22 (19671817) 2
21 (22723498) 2
20 (26681086) 3
19 (27134251) 3
18 (24528508) 4
13 (23520036) 4
MRI area of interest without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 1 5 4 2 2
References Study Quality
28 (25537977) 3
24 (20966327) 4
25 (23192434) 4
23 (25636414) 3
20 (26681086) 3
19 (27134251) 3
18 (24528508) 4
13 (23520036) 4
Image-guided aspiration area of interest Usually not appropriate Expert Consensus Varies Varies 2 2 8 1 3 1 1 1 0 0 1
Bone scan whole body Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 0 1 1 0 0 0 0
References Study Quality
9 (10366117) 1
14 (24315051) 4
Bone scan whole body with SPECT or SPECT/CT area of interest Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 5 0 1 0 0 0 0
References Study Quality
14 (24315051) 4
FDG-PET/CT whole body Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 0 1 0 0 0 0
References Study Quality
14 (24315051) 4
16 (21718320) 4
17 (33476822) 4
CT area of interest with IV contrast Usually not appropriate Limited Varies Varies 1 1 9 1 6 0 0 0 0 0 0
References Study Quality
15 (33281053) 4
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 11 0 5 0 0 0 0 0 0
References Study Quality
15 (33281053) 4
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 8 1 5 2 0 0 0 0 0
Variant 3: Chronic extremity joint pain. Suspect gout. Radiographs normal or inconclusive. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 0 5 2 7
References Study Quality
65 (32669301) 2
64 (30285127) 3
63 (32157468) 2
62 (23291387) 4
61 (30539275) 3
60 (24915980) M
59 (32696059) 3
58 (25972391) 3
55 (31167758) 4
50 (25180122) 4
CT area of interest without IV contrast Usually appropriate Strong Varies Varies 8 8 0 0 0 0 1 2 3 4 6
References Study Quality
55 (31167758) 4
54 (26509070) 1
53 (32880052) 2
52 (30334984) 1
51 (29679210) 1
50 (25180122) 4
49 (29725712) Good
48 (28372824) Good
47 (31089688) Good
15 (33281053) 4
Image-guided aspiration area of interest May be appropriate Limited Varies Varies 6 6 0 0 0 1 7 1 4 1 2
References Study Quality
56 (856219) 4
MRI area of interest without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 5 1 6 1 2 0 0 1 0
References Study Quality
55 (31167758) 4
57 (24080252) 1
MRI area of interest without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 6 0 4 2 4 0 0 0 0
References Study Quality
55 (31167758) 4
57 (24080252) 1
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 0 0 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 12 3 0 0 1 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 2 0 0 0 0 0 0 1
Variant 4: Chronic extremity joint pain. Suspect calcium pyrophosphate dihydrate disease (pseudogout). Radiographs normal or inconclusive. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 3 1 5 2 4
References Study Quality
75 (32988839) 1
74 (30738145) 2
73 (24115756) 2
CT area of interest without IV contrast Usually appropriate Limited Varies Varies 8 8 0 0 0 1 1 2 3 2 6
References Study Quality
70 (33131218) 3
71 (29622016) 2
69 (24703345) 4
Image-guided aspiration area of interest May be appropriate Limited Varies Varies 6 6 0 0 0 0 7 4 2 2 0
References Study Quality
68 (26886247) 3
MRI area of interest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 1 6 1 1 0 1 0 0
References Study Quality
72 (34623546) 4
MRI area of interest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 7 1 1 1 0 0 0
References Study Quality
72 (34623546) 4
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 1 0 1 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 14 0 0 0 1 0 0 0 1
Variant 5: Chronic extremity joint pain. Suspect erosive osteoarthritis. Radiographs normal or inconclusive. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 1 1 5 3 3 0 0 1
References Study Quality
76 (21081530) 1
MRI area of interest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 3 7 2 1 0 1
References Study Quality
23 (25636414) 3
Image-guided aspiration area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 12 0 2 1 0 0 0 0 1
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 4 2 0 0 0 0 0
Bone scan whole body Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
FDG-PET/CT whole body Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 1 1 0 1 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 1 1 0 0 0 0 0 1
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 3 3 5 2 5 3 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.