Applicability of the appropriate use criteria for SPECT myocardial perfusion imaging in Italy: preliminary results

Appropriate use criteria in myocardial perfusion imaging in a tertiary care hospital in South India: An audit

Myocardial perfusion imaging (MPI) is an important investigative tool in the diagnosis and management of coronary artery disease. This investigation has seen a manifold increase in number in past decades as compared to other investigations such as cardiac magnetic resonance imaging/positron emission tomography or computed tomography. In 2005, “Appropriate use criteria (AUC) in cardiac radionuclide imaging” was formulated by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology for effective use of this investigation, later revised in 2009. We assessed the appropriateness of indications for MPI in patients presenting to the nuclear medicine department of a tertiary care hospital according to the latest AUC for cardiac radionuclide imaging. This is a retrospective analysis of all cardiac perfusion scans performed from June 2019 to January 2020 in a tertiary care teaching hospital in South India. All patients' indications for MPI were assessed for appropriateness using AUC 2009 as appropriate, inappropriate, and uncertain indications by two experienced nuclear medicine physicians blinded for results of the test and hospital stay of the patients. A total of 1015 cardiac scans were performed in the given period, which were analyzed. This included 613 males and 402 females, with most of the patients aged above 60 years (n = 640; males = 385, females = 255). Most of the patients had diabetes mellitus or hypertension or both except in 161 patients (15.8%) which did not have either of the comorbidities. Chest pain and/or shortness of breath were the most common presenting complaints. The appropriate indication for imaging was found in 784 patients (77.2%), inappropriate in 121 patients (12%), and uncertain in 110 patients (10.8%). Our results showed appropriate indication to be 77.2% and inappropriate indications as 12% for MPI referrals in a tertiary care teaching hospital, similar to Western literature but can be improved further by continued teaching and awareness campaigns.

Implementation of appropriate use criteria for cardiology tests and procedures: a systematic review and meta-analysis

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.

Drivers of poor medical care

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country

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.

Appropriate Use of Cardiac Stress Testing with Imaging: A Systematic Review and Meta-Analysis

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.

Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis

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.

Downstream clinical consequences of stress cardiovascular magnetic resonance based on appropriate use criteria

BACKGROUND

Appropriate use criteria (AUC) have been developed by professional organizations as a response to the rising costs of imaging, with the goal of optimizing test-patient selection. Consequently, the AUC are now increasingly used by third-party-payers to assess reimbursement. However, these criteria were created by expert consensus and have not been systematically assessed for CMR. The aim of this study was to determine the rates of abnormal stress-CMR and subsequent downstream utilization of angiography and revascularization procedures based on the most recent AUC.

METHODS

300 consecutive patients referred for CMR-stress testing were prospectively enrolled. Two cardiologists reviewed all clinical information before the CMR-stress test and classified the test as "appropriate', "maybe appropriate" or "rarely appropriate" according to the 2013 AUC. Patients were followed for 2 months for the primary outcomes of coronary angiography and/or revascularization.

RESULTS

49.7% of stress CMRs were appropriate, 36.7% maybe appropriate, and 13.6% rarely appropriate. Ischemia was significantly more likely to be seen in the appropriate (18.8%) or maybe appropriate groups (21.8%) than the rarely appropriate group (4.8%) (p = 0.030 and p = 0.014 respectively). Referral for cardiac catheterization was not significantly different in the appropriate (10.1%) and maybe appropriate groups (10.0%) compared to the rarely appropriate group (2.4%) (p = 0.119 and p = 0.127 respectively). No patients undergoing catheterization in the rarely appropriate group went on to require revascularization, in contrast to 53.3% of the appropriate vs 36.4% of the maybe appropriate patients (p = 0.391). Presence of ischemia led to referral for cardiac catheterization in 50.0% of the appropriate group vs 33.3% of the maybe appropriate group (p = 0.225); in contrast to none of the rarely appropriate group.

CONCLUSIONS

The great majority of tests were classified as appropriate or maybe appropriate. Downstream cardiac catheterization rates were similar in all 3 groups. However, rarely appropriate studies never required revascularization, suggesting suboptimal resource utilization. Studies classified as maybe appropriate had similar rates of abnormal findings and led to similar rates of downstream catheterization and revascularization as those that were deemed appropriate. This suggests that consideration could be given to upgrading some of the common maybe appropriate indications to the appropriate category.