0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letter | Health Care Reform

Appropriate Use of Myocardial Perfusion Imaging in a Veteran Population:  Profit Motives and Professional Liability Concerns FREE

David E. Winchester, MD, MS1,2; Ryan Meral, BA3; Scott Ryals, MD4; Rebecca J. Beyth, MD, MSc5,6; Leslee J. Shaw, PhD7,8,9
[+] Author Affiliations
1Cardiology Section, Medical Service, Malcom Randall VA Medical Center, Gainesville, Florida
2Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville
3medical student at the College of Medicine, University of Florida, Gainesville
4Department of Medicine, College of Medicine, University of Florida, Gainesville
5Geriatric Research Education and Clinical Centers (GRECC), Malcom Randall VA Medical Center, Gainesville, Florida
6Division of General Internal Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville
7College of Medicine, University of Florida, Gainesville
8Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
9Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia
JAMA Intern Med. 2013;173(14):1381-1383. doi:10.1001/jamainternmed.2013.953.
Text Size: A A A
Published online

Myocardial perfusion imaging (MPI) is performed millions of times annually in the United States to assess patients for coronary ischemia. Some have expressed concern that MPI is being used inappropriately, possibly because of self-referral profit motives and professional liability fears.1 To inform clinicians about situations in which patients are likely to benefit from MPI testing, appropriate use criteria (AUCs) for MPI were developed, last revised in 2009.2 Prior investigations have applied AUCs to describe the magnitude and patterns of inappropriate testing. Rates of inappropriate testing have ranged from 7% to 24%.3 We hypothesized that the single-payer environment of the Veterans Affairs (VA) health system, which eliminates self-referral profit motive and limits liability concern, will result in less inappropriate use of MPI.

We conducted a retrospective cross-sectional investigation of MPI ordered in a single VA medical center. Our institutional review board reviewed the protocol and waived the requirement for informed consent. Participants were identified from records of MPI performed using the VA Computerized Patient Record System, beginning December 2010. Demographic information, medical history, and information regarding symptoms were gathered to establish associations with inappropriate MPI ordering. Appropriateness categorization was performed on the basis of the 2009 criteria2 and using a data collection instrument endorsed by professional societies and the Imaging in FOCUS initiative for assessment of appropriateness. Patient symptoms that prompted ordering of MPI were attributed to ischemia, unless specifically indicated otherwise. The primary outcomes were the proportion of inappropriate MPI tests and univariate associations between patient characteristics and the likelihood of an inappropriate MPI. Statistical analysis was performed using SPSS, version 20 (IBM). We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)4 statement in designing our investigation.

We identified 332 MPI studies performed between December 1, 2010, and April 11, 2011. The population of patients was predominantly male with high prevalence of obesity, diabetes mellitus, hypertension, and hyperlipidemia (Table). Coronary artery disease and abnormal electrocardiogram results were also common findings. Chest pain was the most commonly reported individual symptom (49.4%); however, typical angina was rare (0.6%). Positron-emission tomography was used for 304 patients (92%) and single-photon–emission computed tomography for the remaining 28 patients (8%).

Table Graphic Jump LocationTable.  Characteristics, Symptoms, and Univariate Associations With Inappropriate Testing in 332 Patients

For all but 4 patients (1%), an indication from the 2009 AUCs could be identified. Study indications were 78% (n = 259) appropriate, 13% (n = 42) inappropriate, and 8% (n = 27) uncertain (eFigure in Supplement). The most common inappropriate MPI indications included testing of patients with low pretest probability who could have undergone treadmill electrocardiogram testing (7 patients [16.7% of total inappropriate MPI]) and asymptomatic patients with low coronary heart disease risk (7 patients [16.7% of total inappropriate MPI]) (eTable in Supplement). Of the 9 preoperative MPI tests reviewed in this investigation, 6 were inappropriate and 3 were appropriate.

Patient characteristics were compared with MPI indications to identify factors associated with inappropriate MPI ordering (Table). The absence of symptoms was associated with a nearly 5-fold higher likelihood of inappropriate testing (odds ratio [OR], 4.80 [95% CI, 2.39-9.66]; P < .001). Both chest pain (OR, 0.07 [95% CI, 0.02-0.20]; P < .001) and diabetes mellitus (OR, 0.37 [95% CI, 0.17-0.80]; P = .01) were associated with a lower likelihood of inappropriate testing.

In this retrospective cross-sectional investigation regarding the appropriate use of MPI in a VA health care setting, we observed that a substantial portion of MPI tests were ordered for inappropriate indications. The findings are in contrast to our initial hypothesis but are similar to those of another VA-based investigation, the results of which were published during our investigation.5

Our hypothesis was based on unique characteristics of the VA patient care environment. First, no self-referral or profit motives exist. Second, whereas the Federal Tort Claims Act permits medical malpractice lawsuits against federally employed physicians, the substantial majority of claims are resolved through administrative processes. Only 3 judgments against the US government were recorded for tort claims in 2010.6 We did not 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 MPI. A recent survey of cardiologists did not find any association between ownership of diagnostic equipment (MPI, catheterization laboratory, computed tomography scanner, or echocardiography laboratory) and concordance with appropriateness categories.7

The magnitude and pattern of inappropriate testing in our investigation are similar to those in prior reports.3 Hendel et al8 observed similar common inappropriate MPI indications, as well as significant associations between asymptomatic patients and inappropriate testing (OR, 22.5 [95% CI, 15.2-33.2]) and lower likelihood of inappropriate testing in patients with diabetes mellitus (OR, 0.4 [95% CI, 0.4-0.5]).

Reasons for the observed patterns of ordering MPI are unclear. Conceivably, commonalities in medical training, independent of postgraduate practice environment, could contribute to an exaggerated perception of benefit of MPI in asymptomatic patients and those at low risk of coronary heart disease. This exaggerated perception of the benefit would also seem to hold true for preoperative risk assessment, with the majority of preoperative MPI in our study having been inappropriately ordered.

Corresponding Author: David E. Winchester, MD, MS, Medical Service, Malcom Randall VA Medical Center, 1601 SW Archer Rd 111D, Gainesville, FL 32608 (david.winchester@va.gov).

Published Online: June 10, 2013. doi:10.1001/jamainternmed.2013.953.

Author Contributions: Dr Winchester had full access to the data and accepts responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Winchester.

Acquisition of data: Winchester, Meral, Ryals.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Winchester, Shaw.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Winchester.

Obtained funding: Winchester.

Administrative, technical, and material support: Meral, Ryals.

Study supervision: Winchester, Beyth, Shaw.

Conflict of Interest Disclosures: None reported.

Funding/Support: This investigation was supported by NIH T35 Training Grant T35-HL007489-28. This material is based on work supported by the Department of Veterans Affairs, Veterans Health Administration.

Role of the Sponsor: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Previous Presentation: This study was presented at the American College of Cardiology Scientific Session; March 11, 2013; San Francisco, California.

Cerqueira  MD.  Eighth Annual Mario S. Verani, MD Memorial Lecture: nuclear cardiology in the era of multimodality cardiac imaging: can we survive? J Nucl Cardiol. 2010;17(2):177-187.
PubMed   |  Link to Article
Hendel  RC, Berman  DS, Di Carli  MF,  et al.  ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119(22):e561-e587.
PubMed   |  Link to Article
Hendel  RC, Thomas  GS.  The time and place for appropriate radionuclide imaging: now and everywhere. J Nucl Cardiol. 2011;18(6):997-999.
PubMed   |  Link to Article
von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573-577.
PubMed   |  Link to Article
Nelson  KH, Willens  HJ, Hendel  RC.  Utilization of radionuclide myocardial perfusion imaging in two health care systems: assessment with the 2009 ACCF/ASNC/AHA appropriateness use criteria. J Nucl Cardiol. 2012;19(1):37-42.
PubMed   |  Link to Article
United States Government Accountability Office. VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete. Washington, DC: United States Government Accountability Office; 2011. Report 12-6R VA Health Care.
Lin  FY, Rosenbaum  LR, Gebow  D,  et al.  Cardiologist concordance with the American College of Cardiology appropriate use criteria for cardiac testing in patients with coronary artery disease. Am J Cardiol. 2012;110(3):337-344.
PubMed   |  Link to Article
Hendel  RC, Cerqueira  M, Douglas  PS,  et al.  A multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria. J Am Coll Cardiol. 2010;55(2):156-162.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable.  Characteristics, Symptoms, and Univariate Associations With Inappropriate Testing in 332 Patients

References

Cerqueira  MD.  Eighth Annual Mario S. Verani, MD Memorial Lecture: nuclear cardiology in the era of multimodality cardiac imaging: can we survive? J Nucl Cardiol. 2010;17(2):177-187.
PubMed   |  Link to Article
Hendel  RC, Berman  DS, Di Carli  MF,  et al.  ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119(22):e561-e587.
PubMed   |  Link to Article
Hendel  RC, Thomas  GS.  The time and place for appropriate radionuclide imaging: now and everywhere. J Nucl Cardiol. 2011;18(6):997-999.
PubMed   |  Link to Article
von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573-577.
PubMed   |  Link to Article
Nelson  KH, Willens  HJ, Hendel  RC.  Utilization of radionuclide myocardial perfusion imaging in two health care systems: assessment with the 2009 ACCF/ASNC/AHA appropriateness use criteria. J Nucl Cardiol. 2012;19(1):37-42.
PubMed   |  Link to Article
United States Government Accountability Office. VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete. Washington, DC: United States Government Accountability Office; 2011. Report 12-6R VA Health Care.
Lin  FY, Rosenbaum  LR, Gebow  D,  et al.  Cardiologist concordance with the American College of Cardiology appropriate use criteria for cardiac testing in patients with coronary artery disease. Am J Cardiol. 2012;110(3):337-344.
PubMed   |  Link to Article
Hendel  RC, Cerqueira  M, Douglas  PS,  et al.  A multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria. J Am Coll Cardiol. 2010;55(2):156-162.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Supplement.

eFigure. Distribution of Appropriate Use Criteria Categories

eTable. Common Overall and Inappropriate Indications

Supplemental Content

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 2

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles