Appropriate Use Criteria for Stress Single-Photon Emission Computed Tomography Sestamibi Studies: A Quality Improvement Project

Study Questions:

What is the impact of an internal quality improvement project (QIP) on compliance with appropriate use criteria (AUC) for single-photon emission computed tomographic sestamibi (SPECT) in a single center?


This is the third in a series of studies from a single center evaluating the adherence to AUC for SPECT. The first study in May 2005, revealed that four indications accounted for 88% of inappropriate studies. These were indication 10, asymptomatic low-risk; indication 32, intermediate-risk surgery good exercise capacity preoperative; indication 1, symptomatic low test probability with interpretable electrocardiogram; and indication 31, preoperative low-risk surgery. Approximately 48% of inappropriate studies were attributable to asymptomatic low-risk patients. A follow-up study in 2006 revealed that the prevalence of inappropriate studies decreased from 14.7 to 7.0. Following this, the authors developed an educational “intervention” including presentations at grand rounds, dissemination of the study summary outlining inappropriate indications, etc. The current study used identical methodology to characterize 273 SPECT patients studied between March 16 and April 4, 2008.


The patients in the 2008 study were similar with respect to demographics and clinical characteristics to the patients studied in 2005 and 2006. The most common indication for SPECT was testing following revascularization (n = 88, 32%), evaluation of symptoms (n = 71, 26%), and follow-up after prior SPECT (n = 61, 22%) and screening in asymptomatic patients (n = 38, 14%). This distribution is similar to that in the previous studies. The rate of inappropriate SPECT studies was 14.4% in May 2005 and had declined to 7.0% in October 2006 (p = 0.004). For the March 2008 cohort, the prevalence of inappropriate studies rose to 11.7% (p = 0.34 compared to 2005; p = 0.06 compared to October 2006).


The authors concluded that a quality improvement project directed at physician education and feedback did not reduce the rate of inappropriate SPECT studies.


This is the third in a series of papers using identical methodology to evaluate adherence to AUC for SPECT imaging in a single institution. The first publication dealt with patients from 2005 and demonstrated a substantial (14.4%) prevalence of inappropriate studies and furthermore identified four separate indications accounting for 88% of inappropriate studies including asymptomatic low-risk patients, which accounted for almost 50% of the inappropriate studies. A follow-up after publication of the AUC in 2006 demonstrated a significant decrease to 7.0% of inappropriate studies. The authors, at that time, engaged in a quality improvement project including grand rounds, publication of one page synopses of these studies, and other intramural educational activities designed to educate the referring physician base, and presumably further decrease the incidence of inappropriate studies. These educational and information sessions occurred predominantly in January 2008, and a third cohort of patients was subsequently evaluated in March of that year. Again, using identical methodology, the authors found that the rate of inappropriate studies had increased from 7.0% in October 2006 to 11.7% in March 2008, representing a substantial trend in worsening of compliance with the AUC (p = 0.06). The reasons for the failure of the educational intervention are unclear. The authors discuss a variety of reasons why the intervention failed, none of which would appear to account for an actual substantial increase in inappropriate studies after the 2006 cohort. AUC exist and are in evolution for virtually all imaging modalities, and the current iteration of each appears well thought out and reasonable from the perspective of clinical care. Of note, the AUC for SPECT are virtually identical to that for stress echocardiography. The fact that a well-organized, well-attended, educational program directed at increasing compliance with AUC failed to do so and even resulted in a regression in appropriate ordering in a fairly closed institution with tremendous resources does not bode well for similar efforts in less structured environments.

Clinical Topics: Noninvasive Imaging, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Prevalence, Quality Improvement, Follow-Up Studies, Echocardiography, Stress, Tomography, Emission-Computed, Single-Photon, Cardiology, Electrocardiography, Patient Compliance

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