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CLINICAL RESEARCH: CARDIAC IMAGING

Application of Appropriateness Criteria to Stress Single-Photon Emission Computed Tomography Sestamibi Studies and Stress Echocardiograms in an Academic Medical Center

Raymond J. Gibbons, MD, FACC^_*,_*, Todd D. Miller, MD, FACC^_*, David Hodge, MSc, Lynn Urban, Philip A. Araoz, MD, Patricia Pellikka, MD, FACC^_* and Robert B. McCully, MD, FACC^_*

^_* Division of Cardiovascular Diseases, Department of Medicine, Mayo Foundation, Mayo Clinic, Rochester, Minnesota
Department of Biostatistics, Mayo Foundation, Mayo Clinic, Rochester, Minnesota
Department of Radiology, Mayo Foundation, Mayo Clinic, Rochester, Minnesota.

Manuscript received July 16, 2007; revised manuscript received September 27, 2007, accepted October 23, 2007.

^_* Reprint requests and correspondence: Dr. Raymond J. Gibbons, Mayo Clinic, Gonda 5, 200 First Street SW, Rochester, Minnesota 55905. (Email: gibbons.raymond{at}mayo.edu).

Objectives: The purpose of this study was to apply published appropriateness criteria for single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in a single academic medical center.

Background: The American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) have developed appropriateness criteria for stress SPECT MPI to address concern about the growth in cardiac imaging studies.

Methods: We retrospectively examined 284 patients who underwent stress SPECT MPI and 298 patients who underwent stress echocardiography before publication of these criteria.

Results: The overall level of agreement in characterizing appropriateness between 2 experienced cardiovascular nurse abstractors was modest (kappa = 0.56), but noticeably poorer (kappa = 0.27) for patients with previous SPECT or echo studies. Similar percentages of each imaging modality were assigned to the 3 appropriateness categories: 64% of stress SPECT and 64% of stress echo studies were classified appropriate; 11% of stress SPECT and 9% of stress echo were of uncertain appropriateness; and 14% of stress SPECT and 18% of stress echo were inappropriate. Of the inappropriate studies, 88% were performed for 1 of 4 indications. Approximately 10% of the patients were unclassifiable.

Conclusions: Application of existing SPECT MPI appropriateness criteria is demanding and requires an established database or detailed data collection, as well as a number of assumptions. Fourteen percent of stress SPECT studies and 18% of stress echo studies were performed for inappropriate reasons. Quality improvement efforts directed at reducing the number of these inappropriate studies may improve efficiency in the health care system.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   ACCF = American College of Cardiology Foundation   ASNC = American Society of Nuclear Cardiology   CI = confidence interval   MPI = myocardial perfusion imaging   PCI = percutaneous coronary intervention   SPECT = single-photon emission computed tomography

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