SAN DIEGO — The way Dr. Raymond J. Gibbons sees it, the best way to practice appropriate single-photon emission computed tomography myocardial perfusion imaging is to apply the appropriateness criteria established by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology.
These criteria grade clinical scenarios with respect to whether they are appropriate or inappropriate uses of SPECT myocardial perfusion imaging (J. Am. Coll. Cardiol. 2005;46:1587–605). When Dr. Gibbons and his associates at the Mayo Clinic Nuclear Cardiology Laboratory in Rochester, Minn., applied the criteria to several hundred patients in their nuclear cardiology laboratory, they discovered that 64% of the SPECT myocardial perfusion imaging studies they did were appropriate, 11% could not be classified, 11% were of uncertain appropriateness, and about 14% were inappropriate.
“We need to reduce this number of inappropriate tests,” Dr. Gibbons said at the annual meeting of the American Society of Nuclear Cardiology. “I would urge all of you to do this same study in your own laboratory. The goal should be to educate ordering physicians to reduce this segment of the pie.”
In Dr. Gibbon's study, four inappropriate indications for SPECT myocardial perfusion imaging accounted for almost all of the inappropriate studies. These included studies in asymptomatic low-risk patients; preoperative studies in patients who were undergoing intermediate-risk surgery and had good exercise capacity; studies in symptomatic patients with a low pretest likelihood of coronary artery disease, an interpretable ECG; and who are able to exercise, and studies conducted as preoperative testing in patients undergoing low-risk surgery.
“Together, these four indications accounted for 88% of the inappropriate studies,” said Dr. Gibbons, who is a codirector of Mayo's Nuclear Cardiology Laboratory. “We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.”
Dr. Gibbons, a former president of the American Heart Association, expressed concern about the future of health care and imaging in the United States. In the summer of 2007 the House of Representatives passed State Children's Health Insurance Program and Medicare reform legislation that eliminated a 9.9% decrease in physician payment in 2008 and a 5% decrease in 2009. That's the good news. The bad news is that in 2010 the sustainable growth rate formula will be replaced with a new system with six separate targets, one of which is imaging.
“Growth in those targets will be limited to the growth in gross domestic product,” Dr. Gibbons said. “Given the interest in CT and MR, and the dramatic growth in cardiac imaging, this will have a draconian effect if it goes into law.”
'We have initiated a program to try to educate our physicians and nurses to reduce these inappropriate studies.' DR. GIBBONS