Overuse of myocardial perfusion imaging is commonplace in the Veterans Affairs (VA) health system, according to a study published June 10 in the JAMA: Internal Medicine.

Additional Resources Full JAMA: IM Study Full JACC: CI Study Journal Scan ACCF/ASNC/ACR/AHA/ ASE/SCCT/SCMR/SNM 2009 AUC for Cardiac Radionuclide Imaging Imaging in FOCUS

The myocardial perfusion imaging report retrospectively compared the indications used to conduct myocardial perfusion imaging studies in 332 patients over a five-month period on the basis of the ACCF/AHA 2009 AUC for Cardiac Radionuclide Imaging using the ACC's Imaging in FOCUS data collection tool. Results showed that indications for myocardial perfusion imaging were appropriate in 78 percent of cases, inappropriate in 13 percent and uncertain in 8 percent. Inappropriate testing was particularly likely in the absence of symptoms and appropriate testing was more likely among patients with diabetes or chest pain.

The study investigators noted that they had expected lower rates of inappropriate use than in previous studies because of the absence of profit motives and self-referral in the VA system. However, they said they did detect a "significant reduction in inappropriate testing in the VA environment, which suggests a lesser role of defensive medicine and self-referral in the inappropriate use of myocardial perfusion imaging."

In an accompanying editorial, Deborah Grady, MD, deputy editor of JAMA: Internal Medicine, wrote, "The facts that VA physicians are salaried and malpractice claims are very uncommon suggest that there are other reasons that physicians order inappropriate tests. This study was small and conducted at a single VA medical center, so the findings should be viewed as hypothesis generating. Nevertheless, it suggests that the culture of over-ordering is ingrained."

A separate study published in JACC: Cardiovascular Imaging  also looked at the Imaging in FOCUS tool, and found that for the 55 participating sites, between April 2010 and December 2011, the proportion of inappropriate cases decreased from 10 percent to 5 percent (p<0.0001). The authors note that their preliminary data suggest that "through the use of a self-directed, quality improvement software and an interactive community, physicians may be able to significantly decrease the proportion of tests not meeting AUC."

Keywords: Myocardial Perfusion Imaging, Quality Improvement, Veterans, Chest Pain, Malpractice, Referral and Consultation, Software, Defensive Medicine, Diabetes Mellitus

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