The time and place for appropriate radionuclide imaging: Now and everywhere

The economics of health care have been a serious source of concern in the United States for the past several decades. Spiraling health care costs and reported profiteering by physicians have garnered increasing public attention. However, it is notable that growth of medical imaging has received much of the notoriety. Although concerns related to increased use of imaging are not unique to the United States, the high US volume of procedures such as SPECT myocardial perfusion imaging has created a rather provincial response which is firmly rooted in our domestic system of payment for non-Medicare patients. Private third party payers have initiated progressively more onerous utilization strategies, including the ever-increasing use of radiology benefits managers (RBM’s). One of the main limitations of RBM utilization management has been their independent creation of ‘‘guidelines’’ determining reimbursement for specific tests and indications. These ‘‘guidelines’’ frequently lack a basis in the medical literature and developed predominately without input from physician specialty and subspecialty societies. The American College of Cardiology (ACC) and American Society of Nuclear Cardiology (ASNC), in addition to other societies, responded to this vacuum with the development of Appropriate Use Criteria (AUC) in 2005, and with an updated version in 2009. The goal of AUC was to provide clinicians, payers, and patients with guidance towards the rational/reasonable use of cardiac imaging, providing an evidence based alternative to RBM policies. Patient safety in imaging is of primary importance, providing the impetus to reduce radiation exposure and improve dosimetry. The technical efforts from the cardiac imaging community to reduce radiation exposure are laudable. However, this approach begins with the determination of whether the procedure itself should be performed. As such, the AUC promotes the concept that the right patient undergoes radionuclide imaging only when potential benefits exceed risks. This is not only a national priority, being a key component of patient-centered imaging, but a worldwide goal. The current paper by Gholamrezanezhad et al demonstrates an international extension of AUC. Limited data are presently available for non-US evaluation of appropriateness of the use of AUC, although findings have now been reported for Canada, England, Sweden, and Germany. This current effort in Iran represents the first application of AUC in a developing country. However, more than geography is in play. The basic structure of AUC is based on risk assessment, that is dependent on the risk model selected (e.g., ATP III, Reynold’s score), each of which was developed for a US population. Other countries, however, may have a markedly different disease prevalence based largely on differences in risk factor prevalence, ethnicity, and access to preventive cardiology care. Each of these risk factors alters the use and value of this risk model. This is supported by a younger population in the current study when compared with other assessments of appropriateness. Three sets of appropriateness determinations were performed in this study: (1) a local panel used their own clinical judgment to categorize the appropriateness of each case, (2) panel assignment according to specific 2005 AUC indications, and (3) panel assignment according to specific 2009 AUC indications. Overall, the authors report levels of appropriateness similar to that found by others (Table 1). The authors unique method to define appropriate testing by a panel of local experts is potentially problematic. First, the rigorous process for the determination of appropriate use emphasized within each of the ACCF AUC documents is based on analysis From the Cardiovascular Division, University of Miami Miller School of Medicine Miami, Miami, FL; and Mission Internal Medical Group, University of California, Irvine, Mission Viejo, CA. Reprint requests: Robert C. Hendel, MD, FASNC, FACC, FAHA, Cardiovascular Division, University of Miami Miller School of Medicine, 1123 NW 14 Street, CRB 1120, Miami, FL 33133; rhendel@med.miami.edu. J Nucl Cardiol 2011;18:997–9. 1071-3581/$34.00 Copyright 2011 American Society of Nuclear Cardiology. doi:10.1007/s12350-011-9439-z