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It is expected that appropriate indications will receive reimbursement and in contrast, inappropriate indications will require additional documentation to justify payment because of unique circumstances or the clinical profile of the patient. An uncertain rating implies possible appropriateness and the criteria firmly state that an uncertain indication should be reimbursed.

In 2007, ASNC reviewed the Appropriateness Criteria for SPECT Imaging to recommend changes. The review resulted in the suggestion to add six new indications and to modify the definitions for "chest pain syndrome" and "CHD high risk." In addition, review of previous indications in the presence of existing and new evidence-based data resulted in the recommendation that the categorization of six indications be re-evaluated.2 These recommendations were carefully considered, along with other suggestions, by the SPECT Appropriate Criteria Writing Group, which is now organizing an update of the Criteria. It is anticipated that the new, revised Criteria will be available by the end of the year. Robert C. Hendel, MD, Chair of the Writing Group and a member of the oversight group for all Appropriateness Criteria and member of the ICANL Board of Directors, emphasizes the need for the ongoing revision of Criteria and the move towards evaluation and implementation.

"We are now entering the phase of clinical use of Appropriateness Criteria. The intent is to assist practices in a more optimal utilization of cardiac imaging procedures," stated Dr. Hendel. "A number of studies have been presented in abstract form or have recently been published and demonstrate that tracking appropriateness using the Criteria is feasible and a potential metric of quality in imaging. Additionally, the ACC has partnered with UnitedHealthcare on and ongoing pilot study using the Appropriateness Criteria to gauge practice pattern and possibly be used instead of pre-certification and the use of radiology benefits managers."

In a recently published study performed at the Mayo Clinic, the Appropriateness Criteria were retrospectively applied to 284 patients who underwent stress SPECT MPI. Their results demonstrated that in 64% of the patients, the studies were performed for appropriate reasons while in 14% of the patients the studies were performed for inappropriate reasons. Interestingly, 88% of inappropriate studies were performed for one out of four indications. Currently, the institution is conducting a staff education program and quality improvement efforts to try to reduce the number of inappropriate studies and improve the efficiency of the institution.3

Can The Appropriateness Criteria
Be Applied To Your Own Practice?

In order to apply the criteria to practice, consider the following questions which help gather the necessary information about the patient in order to effectively use the criteria:

• Is the test being ordered for the detection of CAD?
• Is the test being ordered for risk assessment?
• Is the test being ordered for the assessment of viability or ischemia?
• Is the test being ordered for the evaluation of ventricular function?

Once these and other more specific questions have been answered, the published criteria tables can be accessed to determine appropriateness and/or frequency of testing.

Appropriateness Criteria are not intended to take the place of a physician's best judgment, but rather are a critical tool for both diagnostic physicians and referring physicians to help avoid overuse of imaging procedures and to practice cost-effective medicine. When integrated as part of a laboratory's Quality Improvement program, the Appropriateness Criteria contribute significantly to the ability to provide efficient, quality patient care.

Other published Appropriateness Criteria include Stress Echocardiography (2008), Transthoracic and Transesophageal Echocardiography (2007), and Cardiac CT/CMR (2006).

To obtain a copy of the Appropriateness Criteria, visit the ASNC website at www.asnc.org/section_73.cfm or the ACC website at www.acc.org/qualityandscience/clinical/pdfs/InappropriateUseSPECTMPI-1.pdf.

REFERENCES

1 Brindis RG, Douglas PS, Hendel RC, Peterson ED, Wolk M, Allen J, et al.
ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). J Am Coll Cardiol 2005;46:1587-605.

2 Ward RP, Al-Mallah MH, Grossman GB, Hansen CL, Hendel RC, Kerwin TC, McCallister BD, et al.
American Society of Nuclear Cardiology review of the ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). J Nucl Cardiol 2007;14:e26-e38.

3 Gibbons RJ, Miller TD, Hodge DO, Urban L, Araoz RA, Pellikka PA, et al.
Application of appropriateness criteria to stress SPECT sestamibi studies and stress echocardiograms in an academic medical center. J Am Coll Cardiol, 2008;51:1283-1289, doi:10.1016/j.jacc.2007.10.064