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Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, Hofmann BM. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Eivind Richter Andersen
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Arne Magnus Krokeide
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Lesley J J Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Leti van Bodegom-Vos
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fiona M Clement
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics, The University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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Winchester DE, Merritt J, Waheed N, Norton H, Manja V, Shah NR, Helfrich CD. Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:34-41. [PMID: 32232436 DOI: 10.1093/ehjqcco/qcaa029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 11/13/2022]
Abstract
AIMS The American College of Cardiology appropriate use criteria (AUC) provide clinicians with evidence-informed recommendations for cardiac care. Adopting AUC into clinical workflows may present challenges, and there may be specific implementation strategies that are effective in promoting effective use of AUC. We sought to assess the effect of implementing AUC in clinical practice. METHODS AND RESULTS We conducted a meta-analysis of studies found through a systematic search of the MEDLINE, Web of Science, Cochrane, or CINAHL databases. Peer-reviewed manuscripts published after 2005 that reported on the implementation of AUC for a cardiovascular test or procedure were included. The main outcome was to determine if AUC implementation was associated with a reduction in inappropriate/rarely appropriate care. Of the 18 included studies, the majority used pre/post-cohort designs; few (n = 3) were randomized trials. Most studies used multiple strategies (n = 12, 66.7%). Education was the most common individual intervention strategy (n = 13, 72.2%), followed by audit and feedback (n = 8, 44.4%) and computerized physician order entry (n = 6, 33.3%). No studies reported on formal use of stakeholder engagement or 'nudges'. In meta-analysis, AUC implementation was associated with a reduction in inappropriate/rarely appropriate care (odds ratio 0.62, 95% confidence interval 0.49-0.78). Funnel plot suggests the possibility of publication bias. CONCLUSION We found most published efforts to implement AUC observed reductions in inappropriate/rarely appropriate care. Studies rarely explored how or why the implementation strategy was effective. Because interventions were infrequently tested in isolation, it is difficult to make observations about their effectiveness as stand-alone strategies. STUDY REGISTRATION PROSPERO 2018 CRD42018091602. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018091602.
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Affiliation(s)
- David E Winchester
- Cardiology Section, Malcom Randall VAMC, 1601 SW Archer Rd 111-D, Gainesville, FL, USA.,Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Justin Merritt
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Hannah Norton
- University of Florida College of Medicine, Health Science Center Library, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Veena Manja
- Department of Surgery, University of California Davis, 2315 Stockton Blvd, Sacramento, CA 95817, USA.,VA Northern California Health Care System, 10535 Hospital Way, Mather, CA 95655, USA
| | - Nishant R Shah
- Department of Medicine, Providence VA Medical Center, Brown University Warren Alpert Medical School, 830 Chalkstone Ave, Providence, RI 02908, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Christian D Helfrich
- Seattle-Denver Center for Innovation in Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way Mailstop S-152 Seattle, WA 98108, USA
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Chow CL, Ponnuthurai FA, Allman KC, van Gaal W. The Applicability of the American College of Cardiology Appropriate Use Criteria for Myocardial Perfusion Scintigraphy in Australia. Heart Lung Circ 2018; 27:469-476. [DOI: 10.1016/j.hlc.2017.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 03/27/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
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Kaushal N, Wijeysundera HC, Connelly KA, Roifman I. Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings. J Magn Reson Imaging 2018; 49:e132-e138. [PMID: 29573034 DOI: 10.1002/jmri.26015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/02/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The rapid growth in cardiac imaging utilization has led to the development of appropriate use criteria (AUC) in an effort to control costs. Recently, cardiac MRI has developed into a valuable modality in the evaluation of cardiac disease. However, there are no studies examining the appropriate use of cardiac MRI in clinical practice. PURPOSE To determine the appropriate utilization of cardiac MRI in a large quaternary care institution and to compare percentages of appropriate utilization pre- and postpublication of the AUC document. We hypothesized that percentages of appropriate cardiac MRI utilization will be similar to those of other comparable cardiac imaging modalities and that there would be a significant change in appropriate use pre- and post-AUC publication. STUDY TYPE Retrospective cohort study. POPULATION In all, 2032 consecutive patients undergoing cardiac MRI for the assessment of heart failure between 2012-2016. FIELD STRENGTH 1.5T. ASSESSMENT Data were collected and an appropriateness category was assigned for each cardiac MRI. STATISTICAL TESTS Rates of major cardiac risk factors were compared between those undergoing cardiac MRIs pre- and post-AUC using the chi-square and the Mann-Whitney tests for categorical and continuous variables, respectively. Appropriateness classification was compared pre- and post-AUC publication using the chi-square test. RESULTS There were no significant differences in the prevalence of major cardiovascular risk factors before and after publication of the AUC. 95.5% of all cardiac MRIs were appropriate based on the AUC. Further, there was a significant difference when comparing the appropriateness classification before and after publication of the AUC (P = 0.0003), potentially associated with annual cost savings of ∼$14.8 million. DATA CONCLUSION We report a very high percentage of appropriate use of cardiac MRI and a significant increase in the proportion of tests classified as appropriate after AUC publication. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e132-e138.
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Affiliation(s)
- Nishchay Kaushal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Idan Roifman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
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Appropriateness and Budget Limitations: Effects on the Use of Cardiac Imaging Techniques. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dos Santos MA, Santos MS, Tura BR, Félix R, Brito ASX, De Lorenzo A. Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country. J Nucl Cardiol 2016; 23:1160-1165. [PMID: 27229342 DOI: 10.1007/s12350-016-0505-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/21/2016] [Accepted: 04/05/2016] [Indexed: 01/10/2023]
Abstract
Myocardial perfusion imaging is widely used for the risk stratification of coronary artery disease. In view of its cost, besides radiation issues, judicious evaluation of the appropriateness of its indications is essential to prevent an unnecessary economic burden on the health system. We evaluated, at a tertiary-care, public Brazilian hospital, the appropriateness of myocardial perfusion scintigraphy indications, and estimated the budget impact of applying appropriateness criteria. An observational, cross-sectional study of 190 patients with suspected or known coronary artery disease referred for myocardial perfusion imaging was conducted. The appropriateness of myocardial perfusion imaging indications was evaluated with the Appropriate Use Criteria for Cardiac Radionuclide Imaging published in 2009. Budget impact analysis was performed with a deterministic model. The prevalence of appropriate requests was 78%; of inappropriate indications, 12%; and of uncertain indications, 10%. Budget impact analysis showed that the use of appropriateness criteria, applied to the population referred to myocardial perfusion scintigraphy within 1 year, could generate savings of $ 64,252.04 dollars. The 12% inappropriate requests for myocardial perfusion scintigraphy at a tertiary-care hospital suggest that a reappraisal of MPI indications is needed. Budget impact analysis estimated resource savings of 18.6% with the establishment of appropriateness criteria for MPI.
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Affiliation(s)
- Mauro Augusto Dos Santos
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Rio de Janeiro, RJ, 22240-006, Brazil
| | - Marisa Silva Santos
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Rio de Janeiro, RJ, 22240-006, Brazil
| | - Bernardo Rangel Tura
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Rio de Janeiro, RJ, 22240-006, Brazil
| | - Renata Félix
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Rio de Janeiro, RJ, 22240-006, Brazil
| | - Adriana Soares X Brito
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Rio de Janeiro, RJ, 22240-006, Brazil
| | - Andrea De Lorenzo
- Instituto Nacional de Cardiologia, Rua das Laranjeiras 374, Rio de Janeiro, RJ, 22240-006, Brazil.
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Appropriate Use of Cardiac Stress Testing with Imaging: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0161153. [PMID: 27536775 PMCID: PMC4990235 DOI: 10.1371/journal.pone.0161153] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 07/28/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Appropriate use criteria (AUC) for cardiac stress tests address concerns about utilization growth and patient safety. We systematically reviewed studies of appropriateness, including within physician specialties; evaluated trends over time and in response to AUC updates; and characterized leading indications for inappropriate/rarely appropriate testing. METHODS We searched PubMed (2005-2015) for English-language articles reporting stress echocardiography or myocardial perfusion imaging (MPI) appropriateness. Data were pooled using random-effects meta-analysis and meta-regression. RESULTS Thirty-four publications of 41,578 patients were included, primarily from academic centers. Stress echocardiography appropriate testing rates were 53.0% (95% CI, 45.3%-60.7%) and 50.9% (42.6%-59.2%) and inappropriate/rarely appropriate rates were 19.1% (11.4%-26.8%) and 28.4% (23.9%-32.8%) using 2008 and 2011 AUC, respectively. Stress MPI appropriate testing rates were 71.1% (64.5%-77.7%) and 72.0% (67.6%-76.3%) and inappropriate/rarely appropriate rates were 10.7% (7.2%-14.2%) and 15.7% (12.4%-19.1%) using 2005 and 2009 AUC, respectively. There was no significant temporal trend toward rising rates of appropriateness for stress echocardiography or MPI. Unclassified stress echocardiograms fell by 79% (p = 0.04) with updated AUC. There were no differences between cardiac specialists and internists. CONCLUSIONS Rates of appropriate use tend to be lower for stress echocardiography compared to MPI, and updated AUC reduced unclassified stress echocardiograms. There is no conclusive evidence that AUC improved appropriate use over time. Further research is needed to determine if integration of appropriateness guidelines in academic and community settings is an effective approach to optimizing inappropriate/rarely appropriate use of stress testing and its associated costs and patient harms.
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8
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Elgendy IY, Mahmoud A, Shuster JJ, Doukky R, Winchester DE. Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis. J Nucl Cardiol 2016; 23:680-9. [PMID: 26253327 PMCID: PMC5442883 DOI: 10.1007/s12350-015-0240-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 06/18/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes. METHODS We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method. RESULTS A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10). CONCLUSION Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100277, Gainesville, FL, 32610, USA
| | - Ahmed Mahmoud
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jonathan J Shuster
- Department of Health Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - David E Winchester
- Division of Cardiovascular Medicine, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100277, Gainesville, FL, 32610, USA.
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9
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Marcassa C, Zoccarato O. Radiation Dose Reduction from Radionuclide Myocardial Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-015-9364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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10
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Remfry A, Abrams H, Dudzinski DM, Weiner RB, Bhatia RS. Assessment of inpatient multimodal cardiac imaging appropriateness at large academic medical centers. Cardiovasc Ultrasound 2015; 13:44. [PMID: 26573578 PMCID: PMC4647603 DOI: 10.1186/s12947-015-0037-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/06/2015] [Indexed: 01/03/2023] Open
Abstract
Background Responding to concerns regarding the growth of cardiac testing, the American College of Cardiology Foundation (ACCF) published Appropriate Use Criteria (AUC) for various cardiac imaging modalities. Single modality cardiac imaging appropriateness has been reported but there have been no studies assessing the appropriateness of multiple imaging modalities in an inpatient environment. Methods A retrospective study of the appropriateness of cardiac tests ordered by the inpatient General Internal Medicine (GIM) and Cardiology services at three Canadian academic hospitals was conducted over two one-month periods. Cardiac tests characterized were transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), single-photon emission tomography myocardial perfusion imaging (SPECT), and diagnostic cardiac catheterization. Results Overall, 553 tests were assessed, of which 99.8 % were classifiable by AUC. 91 % of all studies were categorized as appropriate, 4 % may be appropriate and 5 % were rarely appropriate. There were high rates of appropriate use of all modalities by GIM and Cardiology throughout. Significantly more appropriate diagnostic catheterizations were ordered by Cardiology than GIM (93 % vs. 82 %, p = <0.01). Cardiology ordered more appropriate studies overall (94 % vs. 88 %, p = 0.03) but there was no difference in the rate of rarely appropriate studies (3 % vs. 6 %, p = 0.23). Conclusion The ACCF AUC captured the vast majority of clinical scenarios for multiple cardiac imaging modalities in this multi-centered study on Cardiology and GIM inpatients in the acute care setting. The rate of appropriate ordering was high across all imaging modalities. We recommend further work towards improving appropriate utilization of cardiac imaging resources focus on the out-patient setting.
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Affiliation(s)
- Andrew Remfry
- University of Toronto Medical School, Medical Sciences Building, 1 King's College Circle, Toronto, M5S 1A8, Canada
| | - Howard Abrams
- University of Toronto Medical School, Medical Sciences Building, 1 King's College Circle, Toronto, M5S 1A8, Canada.,Peter Munk Cardiac Centre of the University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - David M Dudzinski
- Massachusetts General Hospital, 55 Fruit Sreet, Boston, MA, 02114, USA
| | - Rory B Weiner
- Massachusetts General Hospital, 55 Fruit Sreet, Boston, MA, 02114, USA
| | - R Sacha Bhatia
- University of Toronto Medical School, Medical Sciences Building, 1 King's College Circle, Toronto, M5S 1A8, Canada. .,Peter Munk Cardiac Centre of the University Health Network, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada. .,Women's College Hospital Institute for Health Systems Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,Adjunct Scientist, Institute for Clinical Evaluative Sciences, Division of Cardiology, University Health Network and Women's College Hospital, University of Toronto, 76 Grenville Street, 6th Floor, Toronto, ON, M5S 1B2, Canada.
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Fonseca R, Negishi K, Otahal P, Marwick TH. Temporal changes in appropriateness of cardiac imaging. J Am Coll Cardiol 2015; 65:763-773. [PMID: 25720619 DOI: 10.1016/j.jacc.2014.11.057] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 11/23/2014] [Accepted: 11/24/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is undefined. OBJECTIVES This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests. METHODS Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression. RESULTS New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% [95% confidence interval (CI): 0.75 to 0.84] vs. 85% [95% CI: 0.81 to 0.89]), transesophageal echocardiography (TEE) (89% [95% CI: 0.81 to 0.94] vs. 95% [95% CI: 0.93 to 0.96]) and computed tomography angiography (CTA) (37% [95% CI: 0.21 to 0.55] vs. 55% [95% CI: 0.44 to 0.65]) but not stress echocardiography (53% [95% CI: 0.45 to 0.61] vs. 52% [95% CI: 0.42 to 0.61]) or single-photon emission computed tomography (72% [95% CI: 0.66 to 0.77] vs. 68% [95% CI: 0.60 to 0.74]). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography. CONCLUSIONS Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.
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Affiliation(s)
- Ricardo Fonseca
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Kazuaki Negishi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Thomas H Marwick
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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12
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Hendel RC. The value and appropriateness of positron emission tomography: an evolving tale. J Nucl Cardiol 2015; 22:16-21. [PMID: 25150093 DOI: 10.1007/s12350-014-9962-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/21/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Robert C Hendel
- University of Miami Miller School of Medicine, Miami, FL, 33133, USA,
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13
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Doukky R, Hayes K, Frogge N. Are cardiologists truly better at appropriately selecting patients for stress myocardial perfusion imaging? Int J Cardiol 2014; 176:285-6. [PMID: 25042647 DOI: 10.1016/j.ijcard.2014.06.087] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 06/29/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Rami Doukky
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, United States; Division of Cardiology, Rush University Medical Center, Chicago, IL, United States.
| | - Kathleen Hayes
- Division of Cardiology, Rush University Medical Center, Chicago, IL, United States
| | - Nathan Frogge
- Division of Cardiology, Rush University Medical Center, Chicago, IL, United States
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Medolago G, Marcassa C, Alkraisheh A, Campini R, Ghilardi A, Giubbini R. Applicability of the appropriate use criteria for SPECT myocardial perfusion imaging in Italy: preliminary results. Eur J Nucl Med Mol Imaging 2014; 41:1695-700. [PMID: 24633473 DOI: 10.1007/s00259-014-2743-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/21/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Clinical applicability of the appropriate use criteria for SPECT myocardial perfusion imaging has not yet been evaluated in Italy. We investigated the applicability of the Appropriate Use Criteria (AUC) in Italy. METHODS The indications for testing were prospectively recorded in three different nuclear cardiology laboratories: a general hospital, an academic hospital, and a tertiary centre. Indications were categorized as appropriate, uncertain or inappropriate according to the 2009 AUC; the specialty of the ordering physician was also noted. SPECT results were classified as: normal, probably normal, uncertain, probably abnormal, abnormal. The presence and severity of ischaemia were also noted. RESULTS Over a 9-month period, 2,134 patients (age 67 ± 10 years, 68 % men) were evaluated (62 % exercise stress test). On average, there were 700 (84 %) appropriate, 73 (7 %) inappropriate and 93 (9 %) uncertain tests. The rates for the appropriateness of indications were comparable in men and women (84 % and 83 %, not significant). As expected, the rate of nonnormal studies was higher (58 %) for appropriate than for inappropriate (33 %) indications. Appropriateness was lower in the tertiary centre (74 %), and uncertain (16 %) and inappropriate (10 %) indications were more common; this was related to the higher rate of outpatients scheduled by nonhospital cardiologists (37 %). The most common indications associated with inappropriate testing were: chest pain, low likelihood of coronary artery disease, interpretable ECG and able to exercise (29 %), and asymptomatic <2 years after percutaneous coronary intervention (24 %). CONCLUSION In this preliminary evaluation of the AUC in Italy, the majority of studies were classified as appropriate, but a consistent proportion of scheduled SPECT studies, particularly by nonhospital cardiologists, were still categorized as uncertain or inappropriate. Educational approaches should be implemented to reduce the rate of less appropriate examinations. However, a substantial proportion (33 %) of inappropriate studies were classified as nonnormal, with 26 % of these patients having ischaemia.
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Affiliation(s)
- G Medolago
- Nuclear Medicine Department, Bergamo, Italy
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