Higher imaging quality makes cardiac positron emission tomography (PET) desirable for evaluation of suspected coronary artery disease (CAD). High cost of PET imaging may be offset by reduced utilization and/or improved outcomes.
This retrospective observational study utilized Medicare fee-for-service dataset. Study participants had no CAD diagnosis within 1 year prior to initial imaging. The PET group (PET imaging) and propensity score matched comparison group (single photon emission computed tomography or stress echocardiography) underwent index imaging between January 2014 and December 2016. Outcomes were analyzed using generalized linear models.
Among 144,503 study subjects, 4619 (3.2%) had PET and 139,884 (96.8%) had conventional imaging. After matching, each group had 4619 patients (mean age 74 years, 59% female). The PET group had lower radiation exposure (3.8 milliSievert less per year, 95% CI − 3.96 to − 3.64, P < .0001) and unstable coronary syndrome (incidence rate ratio (IRR) 0.77, 95% CI 0.64-0.94, P = .008). The PET group experienced more hospital admissions (IRR 1.10, 95% CI 1.06-1.15, P < .0001), more use of percutaneous coronary intervention (IRR 1.24, 95% CI 1.02-1.50, P = 0.03), while similar mortality rate (hazard ratio 0.95, 95% CI 0.78-1.14, P = 0.55). The PET group had higher medical spending ($2358.2 vs $1774.3, difference = $583.9 per patient per month, P < .0001).
First-line PET imaging was not associated with reduced levels of utilization and spending. Clinical outcomes were mostly similar.
This is a preview of subscription content, log in to check access.
Buy single article
Instant unlimited access to the full article PDF.
Price includes VAT for USA
Coronary artery bypass grafting
Coronary artery disease
Centers for Medicare and Medicaid Services
Fee for service
Incidence rate ratio
Percutaneous coronary intervention
Positron emission tomography
Per patient per month
Single photon emission computerized tomography
Benjamin EJ, et al. Heart disease and stroke statistics-2017 update: A report from the American Heart Association. Circulation 2017;135:e146-603.
Machac J. Cardiac positron emission tomography imaging. Semin Nucl Med 2005;35:17-36.
Bateman TM, et al. American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging Joint Position Statement on the Clinical Indications for Myocardial Perfusion PET. J Nucl Cardiol 2016;23:1227-31.
Mordi IR, et al. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag 2017;13:427-37.
Hlatky MA, et al. Economic outcomes in the Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in Coronary Artery Disease registry: the SPARC Study. J Am Coll Cardiol 2014;63:1002-8.
Merhige ME, et al. Impact of myocardial perfusion imaging with PET and (82)Rb on downstream invasive procedure utilization, costs, and outcomes in coronary disease management. J Nucl Med 2007;48:1069-76.
van Waardhuizen CN, et al. Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review. Eur Heart J Qual Care Clin Outcomes 2016;2:245-60.
Centers for Medicare and Medicaid, Medicare Claims Processing Manual Chapter 13-Radiology Services and Other Diagnostic Procedures, Department of Health and Human Services, Editor. 2017, CMS: Baltimore, Maryland.
Fortin Y, et al. External validation and comparison of two variants of the Elixhauser comorbidity measures for all-cause mortality. PLoS ONE 2017;12(3):e0174379.
Parsons LS. Performing a 1: N case–control match on propensity score. Seattle: Ovation Research Group; 2004.
Einstein AJ. Effects of radiation exposure from cardiac imaging: how good are the data? J Am Coll Cardiol 2012;59:553-65.
Gerber TC, et al. Ionizing radiation in cardiac imaging: a science advisory from the American Heart Association Committee on Cardiac Imaging of the Council on Clinical Cardiology and Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention. Circulation 2009;119:1056-65.
Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med 2015;34:3661-79.
Hendel RC, 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. J Am Coll Cardiol 2009;53:2201-29.
Cerqueira MD, et al. Recommendations for reducing radiation exposure in myocardial perfusion imaging. J Nucl Cardiol 2010;17:709-18.
Stocker TJ, et al. Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the PROspective multicenter registry on radiaTion dose Estimates of cardiac CT angIOgraphy iN daily practice in 2017 (PROTECTION VI). Eur Heart J 2018;39:3715-23.
Desiderio MC, et al. Current status of patient radiation exposure of cardiac positron emission tomography and single-photon emission computed tomographic myocardial perfusion imaging. Circ Cardiovasc Imaging 2018;11:e007565.
Al Badarin FJ, et al. Drivers of radiation dose reduction with myocardial perfusion imaging: A large health system experience. J Nucl Cardiol 2019. https://doi.org/10.1007/s12350-018-01576-w.
Delbeke D, Segall GM. Status of and trends in nuclear medicine in the United States. J Nucl Med 2011;52:24S-8S.
Daher, N.M., Is Cardiac PET Finally Finding New Avenues for Growth? ModernMedicine Network https://www.diagnosticimaging.com/blog/cardiac-pet-finally-finding-new-avenues-growth) [accessed 11 July 2019], 2016.
Patel KK, et al. Randomized comparison of clinical effectiveness of pharmacologic SPECT and PET MPI in symptomatic CAD patients. JACC Cardiovasc Imaging 2019;12:1821-31.
Foy AJ, et al. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Intern Med 2015;175:428-36.
Gould KL, Goldstein RA, Mullani NA. Economic analysis of clinical positron emission tomography of the heart with rubidium-82. J Nucl Med 1989;30:707-17.
Authors Qinli Ma and Abiy Agiro are employed by HealthCore, Inc, a wholly owned subsidiary of Anthem, Inc. Author Gayathri Sridhar was employed by HealthCore, Inc when the study was conducted. Thomas Powers is employed by AIM Specialty Health, a wholly owned subsidiary of Anthem, Inc. Authors Ma, Agiro, Sridhar, and Powers have no conflicts of interest to disclose.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The authors of this article have provided a PowerPoint file, available for download at SpringerLink, which summarises the contents of the paper and is free for re-use at meetings and presentations. Search for the article DOI on SpringerLink.com.
The funding for this project was provided entirely by Anthem, Inc.
About this article
Cite this article
Ma, Q., Sridhar, G., Power, T. et al. Assessing the downstream value of first-line cardiac positron emission tomography (PET) imaging using real world Medicare fee-for-service claims data. J. Nucl. Cardiol. (2019) doi:10.1007/s12350-019-01974-8
- vascular imaging
- diagnostic and prognostic application