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

Gibbons, Raymond J.; Miller, Todd D.; Hodge, David O.; Urban, Lynn H.; Araoz, Philip A.; Pellikka, Patricia A.; McCully, Robert B.

doi:10.1016/j.jacc.2007.10.064

Cited by 154 publications

(119 citation statements)

References 16 publications

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“…As shown in Table 2, these categorizations for PET appropriate use are similar to those found in the majority of reports with SPECT, [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] although there are some reports of SPECT MPI with higher frequency of inappropriate studies. 19,27 For evaluation of the scintigraphic findings and outcomes, the authors have combined ''appropriate'' with ''uncertain'' categories, which although somewhat controversial, is consistent with the intent of these AUC-''uncertain is assumed to not provide grounds for denial of reimbursement.''…”

supporting

confidence: 72%

The value and appropriateness of positron emission tomography: An evolving tale

Hendel

2015

Journal of Nuclear Cardiology

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supporting

confidence: 72%

The value and appropriateness of positron emission tomography: An evolving tale

Hendel

2015

Journal of Nuclear Cardiology

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“…[5][6][7][8][9] As shown in Table 1, the inappropriate rate demonstrated in this study (45.5%) is more than twice as high as any previously published inappropriate rate. This finding has major implications if it is representative of other community practices in the country.…”

Section: Spect Appropriateness 1597supporting

confidence: 56%

Single-Photon Emission Computed Tomography Appropriateness

Gibbons

Miller

2013

Circulation

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Editorial 1595I n this issue of Circulation, Doukky et al 1 report findings from a cohort of 1511 patients from 11 outpatient community-based practices (20 primary care physicians and 2 cardiologists) in the Chicago metropolitan area. The patients underwent single-photon emission computed tomographic (SPECT) myocardial perfusion imaging and were then followed up for 27±10 months for major adverse cardiac events: death, death or myocardial infarction, and cardiac death or myocardial infarction. The SPECT studies were categorized on the basis of the 2009 appropriate use criteria (AUC) as appropriate, uncertain, or inappropriate. The investigators report that 823 patients (54.5%) underwent SPECT scans that were classified as appropriate or uncertain and 688 patients (45.5%) underwent SPECT scans that were classified as inappropriate. In those patients whose SPECT scans were appropriate or uncertain, abnormal scans were of significant value in predicting major adverse cardiac events with hazard ratios of 3.1 to 3.7 compared with normal scans. However, in those patients undergoing SPECT classified as inappropriate, abnormal SPECT scans did not achieve statistical significance in predicting major adverse cardiac events, although the hazard ratios ranged from 2.3 to 11.8. Regardless of the appropriateness of SPECT, the presence of ischemia on SPECT, reflected in the summed difference score (SDS), predicted subsequent coronary angiography and revascularization. As the investigators indicate, this is the first large study validating the prognostic implications of SPECT AUC, further supporting its clinical utility. In this editorial, we examine both the internal and external validity of this study to place it in context for evidence-based clinicians. Article see p 1634Is the study internally valid? That is, do the data justify the conclusions? This study has a number of strengths, beginning with the size of the cohort and the several-year duration of follow-up. Although follow-up was >99% complete, a number of patients were excluded (n=182) or lost to follow-up (n=14). To their credit, the authors systematically compare these patients with those patients with follow-up data. The differences were modest, suggesting that the exclusion of these patients did not bias the results. The SPECT studies were all acquired on a single dedicated cardiac SPECT camera and interpreted by a single expert nuclear cardiologist, eliminating the variability inherent in different equipment and different interpreters. The SPECT results were categorized into published groupings of the summed stress score and SDS, permitting comparison with extensive previous literature using the summed stress score and SDS.There were some potential methodological weaknesses in the study. Although the authors define their cohort as prospective, the categorization of appropriateness was based on retrospective chart review and "computer-based logic," which is not further defined. We are not told how many observers performed this review and whether they were indepen...

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“…At the other end of the spectrum, the approach to both justification and optimisation of high-dose procedures, such as interventional radiology, cardiology and single photon emission computed tomography or positron emission tomography CT, may not be satisfactory in practice [64,65]. Where referral criteria are not available, justification will be on a case-by-case basis and, thereby, relies exclusively on the knowledge/experience of the referring and performing medical practitioners.…”

Section: Need For Guidelinesmentioning

confidence: 99%