EXPEDITED PUBLICATION
A Multicenter Assessment of the Use of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging With Appropriateness Criteria
Robert C. Hendel, MD*,*,
Manuel Cerqueira, MD ,
Pamela S. Douglas, MD ,
Karen C. Caruth ,
Joseph M. Allen, MA,
Neil C. Jensen, MHA, MBA||,
Wenqin Pan, PhD,
Ralph Brindis, MD¶ and
Michael Wolk, MD#
* Midwest Heart Specialists, Winfield, Illinois
Cleveland Clinic, Cleveland, Ohio
Duke University Medical Center, Durham, North Carolina
American College of Cardiology, Washington, DC
|| UnitedHealthcare, Minneapolis, Minnesota
¶ Oakland Kaiser Medical Center, Oakland, California
# New York Cardiology Associates, New York, New York
Manuscript received August 19, 2009;
revised manuscript received November 2, 2009,
accepted November 2, 2009.
* Reprint requests and correspondence: Dr. Robert C. Hendel, 1 Kingswood Court, Riverwoods, Illinois 60015 (Email: rhendel.cardio{at}yahoo.com).
Presented as a Late Breaking Clinical Trial at the American College of Cardiology Scientific Sessions in Orlando, Florida, on March 29, 2009.
Objectives: The aim of this study was to assess the feasibility of evaluation for appropriate use of radionuclide myocardial perfusion imaging (MPI) in multiple clinical sites and to determine use patterns as well as identify areas of apparent inappropriate use.
Background: Although cardiac imaging is highly valued for decision-making, the growth and expense related to these procedures has raised questions regarding overuse. The publication of appropriate use criteria (AUC), including those for MPI, were designed to provide guidance in the rational use of testing. However, limited data regarding the implementation and evaluation of AUC are available.
Methods: Six diverse clinical sites enrolled consecutive patients undergoing MPI, collecting point-of-service data entered into an online form. An automated algorithm assigned a specific indication from the AUC that was classified as appropriate, uncertain, or inappropriate. Site-specific feedback was later provided to each practice on ordering patterns.
Results: Of the 6,351 patients enrolled, 93% were successfully assigned an appropriateness level. Inappropriate use of MPI was found in 14.4% of patients, with a range of 4% to 22% among practices. Women and younger patients were more likely to undergo inappropriate MPI. Asymptomatic, low-risk patients accounted for 44.5% of inappropriate testing. Elimination of the 5 most common inappropriate use indications would reduce overall imaging volume by 13.2%. Inappropriate use by physicians from within the practice performing imaging was not greater than physicians outside of the practice. Educational feedback might have resulted in reduced inappropriate test ordering in 1 site.
Conclusions: The tracking of appropriate use is feasible in clinical practice, with an automated system that can readily identify practice patterns and targets for educational and quality improvement initiatives. This approach might provide an alternative to utilization management.
Key Words: appropriateness criteria • diagnostic testing • radionuclide imaging • SPECT
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Abbreviations and Acronyms
| | ACCF = American College of Cardiology Foundation | | AUC = appropriate use criteria | | CAD = coronary artery disease | | CHD = coronary heart disease | | MPI = myocardial perfusion imaging | | PCI = percutaneous coronary intervention | | SPECT = single-photon emission computed tomography | | UHC = UnitedHealthcare |
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