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Improvements in imaging technology, along with increasing therapeutic options, have led to an increase in the use of diagnostic imaging. As the fields of nuclear cardiology and other advanced imaging modalities continue to grow, healthcare providers need to understand how to best incorporate these technologies into their daily practice. To assist physicians utilizing nuclear cardiology technology in making these critical decisions, the American College of Cardiology Foundation (ACCF), in conjunction with the American Society of Nuclear Cardiology (ASNC), published the Appropriateness Criteria for SPECT MPI in October 2005.

The goal of the criteria is "to support the delivery of quality cardiovascular care and ensure the effective use of advanced diagnostic imaging techniques." It is hoped that through implementation, the Appropriateness Criteria will weed out inappropriate utilization, increase underutilization in specific at-risk populations, improve imaging quality and facilitate reimbursement in a performance measurement-based system.

As Appropriateness Criteria are an important first step in closing the gap between evidence-based standards of care and everyday clinical practice, the concept is integrated into the ICANL accreditation process as addressed in Part C of the Quality Improvement section within the 2007 ICANL Standards for Nuclear Cardiology, Nuclear Medicine and PET Accreditation. Specifically, appropriateness is discussed as part of Section C2: Quality Improvement Measures. Related to Administrative Quality, appropriateness of procedures is listed as a suggested area to be assessed by the laboratory. In addition, related to Physician Performance, assessing and improving the performance of physicians regarding the quality of medical practice and specifically appropriateness of care, is addressed. Laboratories are encouraged to include these measures when designing their quality improvement programs.

Appropriateness Criteria Defined

Critical in determining appropriateness was agreement on the definition. "An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication."1 Simply stated, the goal is to determine whether an experienced, evidence-based physician, faced with a specific clinical situation would find performing the imaging study an acceptable step in providing good clinical care.

When developing the criteria specific to SPECT MPI, a technical panel rated 52 patient indications on a scale of 1 to 9, evaluating the risks and benefits. Scores that fell in the low range of scores (1-3) signify the generally inappropriate use of SPECT MPI, while ratings at the higher end of the scale (7-9) indicate a generally appropriate use of SPECT MPI. Scenarios that rated from 3.5 to 6.5 were labeled uncertain indicating a need for further research. An uncertain indication does not mean that the imaging test should not be performed or that there is no evidence of benefit.

A patient with chest pain and an intermediate pretest probability of having coronary artery disease whose ECG is uninterpretable or who is unable to exercise presents as an example of an appropriate indication to perform myocardial perfusion imaging. An example of an inappropriate indication would be a patient who doesn't have any symptoms and is a low risk to develop coronary artery disease.

Based on the panel's findings, 13 indications were rated inappropriate, 27 indications were rated appropriate and 12 indications were judged to be "uncertain" and could not be rated as appropriate or inappropriate.

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