Midwest Heart Specialists, Winfield, Illinois, USA.
J Am Coll Cardiol. 2010 Jan 12;55(2):156-62. doi: 10.1016/j.jacc.2009.11.004.
The aim of this study was to assess the feasibility of evaluation for appropriate use of radionuclide myocardial perfusion imaging (MPI) in multiple clinical sites and to determine use patterns as well as identify areas of apparent inappropriate use.
Although cardiac imaging is highly valued for decision-making, the growth and expense related to these procedures has raised questions regarding overuse. The publication of appropriate use criteria (AUC), including those for MPI, were designed to provide guidance in the rational use of testing. However, limited data regarding the implementation and evaluation of AUC are available.
Six diverse clinical sites enrolled consecutive patients undergoing MPI, collecting point-of-service data entered into an online form. An automated algorithm assigned a specific indication from the AUC that was classified as appropriate, uncertain, or inappropriate. Site-specific feedback was later provided to each practice on ordering patterns.
Of the 6,351 patients enrolled, 93% were successfully assigned an appropriateness level. Inappropriate use of MPI was found in 14.4% of patients, with a range of 4% to 22% among practices. Women and younger patients were more likely to undergo inappropriate MPI. Asymptomatic, low-risk patients accounted for 44.5% of inappropriate testing. Elimination of the 5 most common inappropriate use indications would reduce overall imaging volume by 13.2%. Inappropriate use by physicians from within the practice performing imaging was not greater than physicians outside of the practice. Educational feedback might have resulted in reduced inappropriate test ordering in 1 site.
The tracking of appropriate use is feasible in clinical practice, with an automated system that can readily identify practice patterns and targets for educational and quality improvement initiatives. This approach might provide an alternative to utilization management.
本研究旨在评估在多个临床站点评估放射性核素心肌灌注成像（MPI）合理应用的可行性，并确定使用模式，以及识别明显不合理应用的领域。
尽管心脏成像对决策具有重要价值，但这些程序的增长和费用引起了人们对过度使用的质疑。合理使用标准（AUC）的发布，包括 MPI 的 AUC，旨在为测试的合理使用提供指导。然而，关于 AUC 的实施和评估的数据有限。
六个不同的临床站点连续招募接受 MPI 的患者，收集在线表格中的服务点数据。自动算法从 AUC 中分配一个特定的适应症，分为合适、不确定或不合适。然后，为每个实践提供关于订购模式的特定反馈。
在 6351 名入组患者中，93%的患者成功分配了适宜性水平。MPI 的不合理使用在 14.4%的患者中发现，各实践之间的范围为 4%至 22%。女性和年轻患者更有可能接受不合理的 MPI。无症状、低危患者占不合理检测的 44.5%。消除最常见的 5 种不合理应用指征，将减少整体成像量的 13.2%。在进行成像的实践内的医生的不合理使用并不大于实践外的医生。在 1 个站点，教育反馈可能导致不合理检测的订单减少。
在临床实践中，使用自动系统跟踪合理使用是可行的，该系统可以快速识别实践模式和教育及质量改进计划的目标。这种方法可能提供了一种替代利用管理的方法。
