Journal of Nuclear Cardiology

, Volume 23, Issue 4, pp 680–689 | Cite as

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

  • Islam Y. Elgendy
  • Ahmed Mahmoud
  • Jonathan J. Shuster
  • Rami Doukky
  • David E. Winchester
Original Article

Abstract

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.

Keywords

Myocardial perfusion imaging SPECT ischemia myocardial PET 

Abbreviations

ACC

American College of Cardiology

AUC

Appropriate use criteria

CI

Confidence interval

MI

Myocardial infarction

MPI

Myocardial perfusion imaging

MOOSE

Meta-analysis of observational studies in epidemiology

OR

Odds ratio

PET

Positron emission tomography

SPECT

Single-photon emission computed tomography

Notes

Disclosure

None.

Supplementary material

12350_2015_240_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 15 kb)

References

  1. 1.
    Salerno M, Beller GA. Noninvasive assessment of myocardial perfusion. Circ Cardiovasc Imaging 2009;2:412-24.CrossRefPubMedGoogle Scholar
  2. 2.
    Loong CY, Anagnostopoulos C. Diagnosis of coronary artery disease by radionuclide myocardial perfusion imaging. Heart 2004;90:v2-9.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Levin DC, Rao VM, Parker L, Frangos AJ, Intenzo CM. Recent payment and utilization trends in radionuclide myocardial perfusion imaging: Comparison between self-referral and referral to radiologists. J Am Coll Radiol 2009;6:437-41.CrossRefPubMedGoogle Scholar
  4. 4.
    Lucas FL, DeLorenzo MA, Siewers AE, Wennberg DE. Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001. Circulation 2006;113:374-9.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    McNulty EJ, Hung Y, Almers LM, Go AS, Yeh RW. Population trends from 2000-2011 in nuclear myocardial perfusion imaging use. JAMA 2014;311:1248-9.CrossRefPubMedGoogle Scholar
  6. 6.
    Hendel RC. Utilization management of cardiovascular imaging: Pre-certification and appropriateness. JACC Cardiovasc Imaging 2008;1:241-8.CrossRefPubMedGoogle Scholar
  7. 7.
    Iglehart JK. The new era of medical imaging—progress and pitfalls. N Engl J Med 2009;360:1030-7.CrossRefPubMedGoogle Scholar
  8. 8.
    Brindis RG, Douglas PS, Hendel RC, Peterson ED, Wolk MJ, Allen JM, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol 2005;46:1587-605.CrossRefPubMedGoogle Scholar
  9. 9.
    Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation 2009;119:e561-87.CrossRefPubMedGoogle Scholar
  10. 10.
    Mahajan A, Bal S, Hahn H. Myocardial perfusion imaging determination using an appropriate use smartphone application. J Nucl Cardiol 2015;22:66-71.CrossRefPubMedGoogle Scholar
  11. 11.
    Oliveira AD, Rezende MF, Corrêa R, Mousinho R, Azevedo JC, Miranda SM, et al. Applicability of the appropriate use criteria for myocardial perfusion scintigraphy. Arq Bras Cardiol 2014;103:375-81.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Winchester DE, Hymas J, Meral R, Nguyen D, Dusaj R, Shaw LJ, et al. Clinician-dependent variations in inappropriate use of myocardial perfusion imaging: Training, specialty, and location. J Nucl Cardiol 2014;21:598-604.CrossRefPubMedGoogle Scholar
  13. 13.
    Lalude OO, Gutarra MF, Pollono EN, Lee S, Tarwater PM. Inappropriate utilization of SPECT myocardial perfusion imaging on the USA-Mexico border. J Nucl Cardiol 2014;21:544-52.CrossRefPubMedGoogle Scholar
  14. 14.
    Singh M, Babayan Z, Harjai KJ, Dedhia P, Sattur S, Jagasia DH. Utilization patterns of single-photon emission cardiac tomography myocardial perfusion imaging studies in a rural tertiary care setting. Clin Cardiol. 2014;37:67-72.CrossRefPubMedGoogle Scholar
  15. 15.
    Aldweib N, Negishi K, Seicean S, Jaber WA, Hachamovitch R, Cerqueira M, et al. Appropriate test selection for single-photon emission computed tomography imaging: Association with clinical risk, posttest management, and outcomes. Am Heart J 2013;166:581-8.CrossRefPubMedGoogle Scholar
  16. 16.
    Gupta A, Tsiaras SV, Dunsiger SI, Tilkemeier PL. Gender disparity and the appropriateness of myocardial perfusion imaging. J Nucl Cardiol 2011;18:588-94.CrossRefPubMedGoogle Scholar
  17. 17.
    Koh AS, Flores JL, Keng FY, Tan RS, Chua TS. Evaluation of the American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria for SPECT myocardial perfusion imaging in an Asian tertiary cardiac center. J Nucl Cardiol 2011;18:324-30.CrossRefPubMedGoogle Scholar
  18. 18.
    Mehta R, Ward RP, Chandra S, Agarwal R, Williams KA. Evaluation of the American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria for SPECT myocardial perfusion imaging. J Nucl Cardiol 2008;15:337-44.CrossRefPubMedGoogle Scholar
  19. 19.
    Gibbons RJ, Miller TD, Hodge D, Urban L, Araoz PA, Pellikka P, et al. Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center. J Am Coll Cardiol 2008;51:1283-9.CrossRefPubMedGoogle Scholar
  20. 20.
    Doukky R, Hayes K, Frogge N, Balakrishnan G, Dontaraju VS, Rangel MO, et al. Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging. Circulation 2013;128:1634-43.CrossRefPubMedGoogle Scholar
  21. 21.
    Winchester DE, Chauffe RJ, Meral R, Nguyen D, Ryals S, Dusaj R, et al. Clinical utility of inappropriate positron emission tomography myocardial perfusion imaging: Test results and cardiovascular events. J Nucl Cardiol 2015;22:9-15.CrossRefPubMedGoogle Scholar
  22. 22.
    Koh AS, Flores JL, Keng FY, Tan RS, Chua TS. Correlation between clinical outcomes and appropriateness grading for referral to myocardial perfusion imaging for preoperative evaluation prior to non-cardiac surgery. J Nucl Cardiol 2012;19:277-84.CrossRefPubMedGoogle Scholar
  23. 23.
    Fonseca R, Negishi K, Otahal P, Marwick TH. Temporal changes in appropriateness of cardiac imaging. J Am Coll Cardiol 2015;65:763-73.CrossRefPubMedGoogle Scholar
  24. 24.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177-88.CrossRefPubMedGoogle Scholar
  25. 25.
    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: A proposal for reporting. JAMA 2000;283:2008-12.CrossRefPubMedGoogle Scholar
  26. 26.
    Medolago G, Marcassa C, Alkraisheh A, Campini R, Ghilardi A, Giubbini R. Applicability of the appropriate use criteria for SPECT myocardial perfusion imaging in Italy: Preliminary results. Eur J Nucl Med Mol Imaging 2014;41:1695-700.CrossRefPubMedGoogle Scholar
  27. 27.
    Johnson TV, Rose GA, Fenner DJ, Rozario NL. Improving appropriate use of echocardiography and single-photon emission computed tomographic myocardial perfusion imaging: A continuous quality improvement initiative. J Am Soc Echocardiogr 2014;27:749-57.CrossRefPubMedGoogle Scholar
  28. 28.
    Khawaja FJ, Jouni H, Miller TD, Hodge DO, Gibbons RJ. Downstream clinical implications of abnormal myocardial perfusion single-photon emission computed tomography based on appropriate use criteria. J Nucl Cardiol 2013;20:1041-8.CrossRefPubMedGoogle Scholar
  29. 29.
    Lin FY, Dunning AM, Narula J, Shaw LJ, Gransar H, Berman DS, et al. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: A prospective multicenter study. J Am Coll Cardiol 2013;62:308-16.CrossRefPubMedGoogle Scholar
  30. 30.
    Moralidis E, Papadimitriou N, Stathaki M, Xourgia X, Spyridonidis T, Fotopoulos A, et al. A multicenter evaluation of the appropriate use of single-photon emission tomography myocardial perfusion imaging in Greece. J Nucl Cardiol 2013;20:275-83.CrossRefPubMedGoogle Scholar
  31. 31.
    Soine LA, Cunningham SL, Motzer SA, Inoue LY, Caldwell JH. Application of appropriate use criteria for stress myocardial perfusion imaging at two academic medical centers: Compliance and association with image findings. J Am Acad Nurse Pract 2012;24:200-8.CrossRefPubMedGoogle Scholar
  32. 32.
    Nelson KH, Willens HJ, Hendel RC. Utilization of radionuclide myocardial perfusion imaging in two health care systems: Assessment with the 2009 ACCF/ASNC/AHA appropriateness use criteria. J Nucl Cardiol 2012;19:37-42.CrossRefPubMedGoogle Scholar
  33. 33.
    Gholamrezanezhad A, Shirafkan A, Mirpour S, Rayatnavaz M, Alborzi A, Mogharrabi M, et al. Appropriateness of referrals for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a developing community: A comparison between 2005 and 2009 versions of ACCF/ASNC appropriateness criteria. J Nucl Cardiol 2011;18:1044-52.CrossRefPubMedGoogle Scholar
  34. 34.
    Druz RS, Phillips LM, Sharifova G. Clinical evaluation of the appropriateness use criteria for single-photon emission-computed tomography: Differences by patient population, physician specialty, and patient outcomes. ISRN Cardiol 2011;2011:798318.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Carryer DJ, Hodge DO, Miller TD, Askew JW, Gibbons RJ. Application of appropriateness criteria to stress single photon emission computed tomography sestamibi studies: A comparison of the 2009 revised appropriateness criteria to the 2005 original criteria. Am Heart J 2010;160:244-9.CrossRefPubMedGoogle Scholar
  36. 36.
    Hendel RC, Cerqueira M, Douglas PS, Caruth KC, Allen JM, Jensen NC, et al. A multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria. J Am Coll Cardiol 2010;55:156-62.CrossRefPubMedGoogle Scholar
  37. 37.
    Ronan G, Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Nucl Cardiol 2014;21:192-220.CrossRefPubMedGoogle Scholar
  38. 38.
  39. 39.
    Tilkemeier P, Wang TY, Lytle BL, Denton EA. ASNC ImageGuide™: Cardiovascular imaging data registry. J Nucl Cardiol 2013;20:1186-7.CrossRefPubMedGoogle Scholar
  40. 40.
    Doukky R, Hayes K, Frogge N. Are cardiologists truly better at appropriately selecting patients for stress myocardial perfusion imaging? Int J Cardiol 2014;176:285-6.CrossRefPubMedGoogle Scholar
  41. 41.
    Lin FY, Rosenbaum LR, Gebow D, Kim RJ, Wolk MJ, Patel MR, et al. Cardiologist concordance with the American College of Cardiology appropriate use criteria for cardiac testing in patients with coronary artery disease. Am J Cardiol 2012;110:337-44.CrossRefPubMedGoogle Scholar
  42. 42.
    Dunne RM, Ip IK, Abbett S, Gershanik EF, Raja AS, Hunsaker A, et al. Effect of evidence-based clinical decision support on the use and yield of CT pulmonary angiographic imaging in hospitalized patients. Radiology 2015;276:167-74.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Moriarity AK, Klochko C, O’Brien M, Halabi S. The effect of clinical decision support for advanced inpatient imaging. J Am Coll Radiol 2015;12:358-63.CrossRefPubMedGoogle Scholar
  44. 44.
    Jenkins HJ, Hancock MJ, French SD, Maher CG, Engel RM, Magnussen JS. Effectiveness of interventions designed to reduce the use of imaging for low-back pain: A systematic review. CMAJ 2015;187:401-8.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Doukky R, Hayes K, Frogge N, Nazir NT, Collado FM, Williams KA. Impact of insurance carrier, prior authorization and socioeconomic status on appropriate use of SPECT myocardial perfusion imaging in private community-based office practice. Clin Cardiol 2015;38:267-73.CrossRefPubMedGoogle Scholar
  46. 46.
    McCully RB, Pellikka PA, Hodge DO, Araoz PA, Miller TD, Gibbons RJ. Applicability of appropriateness criteria for stress imaging: Similarities and differences between stress echocardiography and single-photon emission computed tomography myocardial perfusion imaging criteria. Circ Cardiovasc Imaging 2009;2:213-8.CrossRefPubMedGoogle Scholar
  47. 47.
    Ye S, Rabbani LE, Kelly CR, Kelly MR, Lewis M, Paz Y, et al. Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging. Circ Cardiovasc Qual Outcomes 2015;8:23-9.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Hernán MA, Clayton D, Keiding N. The Simpson’s paradox unraveled. Int J Epidemiol 2011;40:780-5.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Winchester DE, Meral R, Ryals S, Beyth RJ, Shaw LJ. Appropriate use of myocardial perfusion imaging in a veteran population: Profit motives and professional liability concerns. JAMA Intern Med 2013;173:1381-3.CrossRefPubMedGoogle Scholar
  50. 50.
    Gibbons RJ, Askew JW, Hodge D, Kaping B, Carryer DJ, Miller T. Appropriate use criteria for stress single-photon emission computed tomography sestamibi studies: A quality improvement project. Circulation 2011;123:499-503.CrossRefPubMedGoogle Scholar
  51. 51.
    Gibbons RJ, Askew JW, Hodge D, Miller TD. Temporal trends in compliance with appropriateness criteria for stress single-photon emission computed tomography sestamibi studies in an academic medical center. Am Heart J 2010;159:484-9.CrossRefPubMedGoogle Scholar
  52. 52.
    Gertz ZM, O’Donnell W, Raina A, Litwack AJ, Balderston JR, Goldberg LR. Application of appropriate use criteria to cardiac stress testing in the hospital setting: Limitations of the criteria and areas for improved practice. Clin Cardiol 2015;38:8-12.CrossRefPubMedGoogle Scholar
  53. 53.
    Levin DC, Intenzo CM, Rao VM, Frangos AJ, Parker L, Sunshine JH. Comparison of recent utilization trends in radionuclide myocardial perfusion imaging among radiologists and cardiologists. J Am Coll Radiol 2005;2:821-4.CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2015

Authors and Affiliations

  • Islam Y. Elgendy
    • 1
  • Ahmed Mahmoud
    • 2
  • Jonathan J. Shuster
    • 3
  • Rami Doukky
    • 4
  • David E. Winchester
    • 1
  1. 1.Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleUSA
  2. 2.Department of MedicineUniversity of Florida College of MedicineGainesvilleUSA
  3. 3.Department of Health Outcomes and PolicyUniversity of FloridaGainesvilleUSA
  4. 4.Division of CardiologyRush University Medical CenterChicagoUSA

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