Applicability of the appropriate use criteria for SPECT myocardial perfusion imaging in Italy: preliminary results

Clinical applicability of the appropriate use criteria for SPECT myocardial perfusion imaging has not yet been evaluated in Italy. We investigated the applicability of the Appropriate Use Criteria (AUC) in Italy.

The indications for testing were prospectively recorded in three different nuclear cardiology laboratories: a general hospital, an academic hospital, and a tertiary centre. Indications were categorized as appropriate, uncertain or inappropriate according to the 2009 AUC; the specialty of the ordering physician was also noted. SPECT results were classified as: normal, probably normal, uncertain, probably abnormal, abnormal. The presence and severity of ischaemia were also noted.

Over a 9-month period, 2,134 patients (age 67 ± 10 years, 68 % men) were evaluated (62 % exercise stress test). On average, there were 700 (84 %) appropriate, 73 (7 %) inappropriate and 93 (9 %) uncertain tests. The rates for the appropriateness of indications were comparable in men and women (84 % and 83 %, not significant). As expected, the rate of nonnormal studies was higher (58 %) for appropriate than for inappropriate (33 %) indications. Appropriateness was lower in the tertiary centre (74 %), and uncertain (16 %) and inappropriate (10 %) indications were more common; this was related to the higher rate of outpatients scheduled by nonhospital cardiologists (37 %). The most common indications associated with inappropriate testing were: chest pain, low likelihood of coronary artery disease, interpretable ECG and able to exercise (29 %), and asymptomatic <2 years after percutaneous coronary intervention (24 %).

In this preliminary evaluation of the AUC in Italy, the majority of studies were classified as appropriate, but a consistent proportion of scheduled SPECT studies, particularly by nonhospital cardiologists, were still categorized as uncertain or inappropriate. Educational approaches should be implemented to reduce the rate of less appropriate examinations. However, a substantial proportion (33 %) of inappropriate studies were classified as nonnormal, with 26 % of these patients having ischaemia.