Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center

Objectives The purpose of this study was to apply published appropriateness criteria for single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in a single academic medical center. Background The American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) have developed appropriateness criteria for stress SPECT MPI to address concern about the growth in cardiac imaging studies. Methods We retrospectively examined 284 patients who underwent stress SPECT MPI and 298 patients who underwent stress echocardiography before publication of these criteria. Results The overall level of agreement in characterizing appropriateness between 2 experienced cardiovascular nurse abstractors was modest (kappa = 0.56), but noticeably poorer (kappa = 0.27) for patients with previous SPECT or echo studies. Similar percentages of each imaging modality were assigned to the 3 appropriateness categories: 64% of stress SPECT and 64% of stress echo studies were classified appropriate; 11% of stress SPECT and 9% of stress echo were of uncertain appropriateness; and 14% of stress SPECT and 18% of stress echo were inappropriate. Of the inappropriate studies, 88% were performed for I of 4 indications. Approximately 10% of the patients were unclassifiable. Conclusions Application of existing SPECT MPI appropriateness criteria is demanding and requires an established database or detailed data collection, as well as a number of assumptions. Fourteen percent of stress SPECT studies and 18% of stress echo studies were performed for inappropriate reasons. Quality improvement efforts directed at reducing the number of these inappropriate studies may improve efficiency in the health care system.