Author + information
- Received August 19, 2009
- Revision received November 2, 2009
- Accepted November 2, 2009
- Published online January 12, 2010.
- 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#
- ↵*Reprint requests and correspondence:
Dr. Robert C. Hendel, 1 Kingswood Court, Riverwoods, Illinois 60015
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.
Supported by grants from the American College of Cardiology Foundationand UnitedHealthcare.
Dr. Cerqueira is a consultant and on the Speakers' Bureau of GE Healthcare and Astellas Pharma, and is a consultant for Nordion. Joseph Allen is an employee of the American College of Cardiology. Neil Jensen is an employee of United HealthCare. Of note, UnitedHealthcare and its employees had involvement in this trial limited to partial financial support and in identifying candidate trial sites.
Presented as a Late Breaking Clinical Trial at the American College of Cardiology Scientific Sessions in Orlando, Florida, on March 29, 2009.
- Received August 19, 2009.
- Revision received November 2, 2009.
- Accepted November 2, 2009.
- American College of Cardiology Foundation