Temporal Changes in Appropriateness of Cardiac Imaging | Journal Scan

Study Questions:

What is the impact of appropriate use criteria (AUC) on utilization of transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), computed tomography angiography (CTA), stress echocardiography (SE), and single-photon emission computed tomography (SPECT)?


An extensive literature review and meta-analysis was undertaken of all publications related to the above-noted modalities and AUC. For each imaging modality, AUC from the original publication and follow-up publications were available for comparison. The time frame of publication of AUC to publication of results was also taken as a measure of impact of AUC on utilization. The primary endpoint was a proportion of appropriate tests in the total sample of each evaluated report.


Comparing the initial AUC to revised AUC, the proportion of appropriate TTE increased from 80% to 85%, for TEE from 89% to 95%, and for CTA from 37% to 55%. For SE, comparing the two time points, the percentage of appropriate studies was 53% versus 52%, and for SPECT 72% versus 68%. Considering TTE, there was no correlation between the proportion of appropriate TTE for the 2007 AUC; however, there was a positive correlation between the proportion of appropriateness in year of publication for the 2011 AUC (p = 0.01). For the 2007 TEE AUC and 2006 CT AUC, there was a significant decrease in the proportion of appropriate studies over time. No association between appropriateness and year of publication was identified for SE, CT, or SPECT.


Reported rates of appropriate utilization improved for TTE and CT, but not SE and TEE when comparing the initial AUC and second-version AUC time frames.


AUC were developed for multiple cardiac imaging modalities in an attempt to improve the legitimate and appropriate utilization of each technique. The AUC are under continuous evolution, and this report documents adherence to appropriate use for two different time frames for each of five different imaging modalities. The data support an improvement in adherence to appropriate use for TTE and CT, but no improvement and possibly decline for other imaging modalities, especially stress imaging modalities. This has occurred in a time frame during which the volume of cardiac imaging was serially decreasing after 2009. It appears that there may not be a clear link between the decrease in utilization and implementation of the AUC. Several intriguing findings are uncovered by this meta-analysis including an increase in rarely appropriate SE studies from 18% to 27% and from 11% to 20% for SPECT imaging when comparing the old and new editions of AUC. The data presented here are not sufficient to provide an explanation for this phenomenon. Not addressed or not able to be addressed in this study would be any concurrent decrease in more expensive and invasive procedures for evaluating coronary disease such as angiography. If a wider and less appropriate utilization of stress testing techniques (although ‘not appropriate in a pure sense’) resulted in a decrease of utilization of invasive and more expensive techniques, then there may be a net benefit which needs to be elucidated. It should be emphasized that the reported studies evaluated in this analysis were exclusively derived from academic medical centers while a majority of cardiovascular imaging is performed in community practice, and as such, the reports evaluating an adherence to AUC may not be reflective of community practice. While for some imaging modalities but not others, there appears to have been an increase in adherence to AUC over time, no definite link between adherence to AUC and the actual reduction in utilization can be demonstrated at this time.

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

Keywords: Cardiac Imaging Techniques, Echocardiography, Stress, Echocardiography, Transesophageal, Exercise Test, Tomography, Emission-Computed, Single-Photon, Academic Medical Centers

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