Impact of the Publication of Appropriate Use Criteria on Utilization Rates of Myocardial Perfusion Imaging Studies in Ontario, Canada: A Population‐Based Study

Abstract

BackgroundConcern regarding overutilization of cardiac imaging has led to the development of appropriate use criteria (AUC). Myocardial perfusion imaging (MPI) is one of the most commonly used cardiac imaging modalities worldwide. Despite multiple iterations of AUC, there is currently no evidence regarding their real‐world impact on population‐based utilization rates of MPI. Our goal was to assess the impact of the AUC on rates of MPI in Ontario, Canada. We hypothesized that publication of the AUC would be associated with a significant reduction in MPI rates.Methods and ResultsWe conducted a retrospective cohort study of the adult population of Ontario from January 1, 2000, to December 31, 2015. Age‐ and sex‐standardized rates were compared from 4 different periods intersected by 3 published iterations of the AUC. Overall, 3 072 611 MPI scans were performed in Ontario during our study period. The mean monthly rate increased from 14.1/10 000 in the period from January 2000 to October 2005 to 18.2/10 000 between November 2005 and June 2009. After this point in time, there was a reduction in rates, falling to a mean monthly rate of 17.1/10 000 between March 2014 and December 2015. Time series analysis revealed that publication of the 2009 AUC was associated with a significant reduction in MPI rates (P<0.001). This translated into ≈88 849 fewer MPI scans at a cost savings of ≈72 million Canadian dollars.ConclusionsOur results reflect a potential real‐world impact of the 2009 MPI AUC by demonstrating evidence of a significant effect on population‐based rates of MPI.

Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings

“…Thus, it is possible that publication of the AUCs was an important driver in the noted improvements in appropriate testing in our patient cohort. Further, our findings of potential cost savings arising from the publication of the AUCs is consistent with other research that has reported a similar impact for other imaging modalities . This work adds to the current literature that has already established the cost‐effectiveness and potential cost savings of cardiac MRI …”

“…The drivers of ordering patterns for noninvasive diagnostic testing are complex. However, other studies have linked publication of AUCs to direct reductions in utilization of imaging tests . Further, the observation of an increased percentage of appropriate testing after publication of AUCs has been reported with other imaging modalities such as TTE, CTA, and TEE .…”

“…Some show a high adherence to AUCs, while others do not. Likewise, some studies report a significant improvement in appropriate utilization of cardiac imaging testing after publication of AUCs while others show no effect or even an increase in inappropriate utilization …”

“…[1][2][3][4][5] There have been several studies examining adherence to AUC and their impact on the utilization of cardiac imaging modalities such as echocardiography, computed tomography angiography, and myocardial perfusion imaging. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] These studies have reported mixed results. Some show a high adherence to AUCs, while others do not.…”

“…Likewise, some studies report a significant improvement in appropriate utilization of cardiac imaging testing after publication of AUCs while others show no effect or even an increase in inappropriate utilization. 2,8,9,22 Over the past 25 years, cardiac magnetic resonance imaging (cardiac MRI) has developed into an increasingly valuable and versatile imaging modality in the evaluation of cardiac structure, function, and myocardial tissue characterization, in particular in patients with heart failure. [23][24][25][26] As of January 1, 2020, ordering physicians in the United States will be required to consult with AUC prior to ordering outpatient MRI scans.…”