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Abstract

Background:

Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is undefined.

Objectives:

This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests.

Methods:

Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression.

Results:

New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% [95% confidence interval (CI): 0.75 to 0.84] vs. 85% [95% CI: 0.81 to 0.89]), transesophageal echocardiography (TEE) (89% [95% CI: 0.81 to 0.94] vs. 95% [95% CI: 0.93 to 0.96]) and computed tomography angiography (CTA) (37% [95% CI: 0.21 to 0.55] vs. 55% [95% CI: 0.44 to 0.65]) but not stress echocardiography (53% [95% CI: 0.45 to 0.61] vs. 52% [95% CI: 0.42 to 0.61]) or single-photon emission computed tomography (72% [95% CI: 0.66 to 0.77] vs. 68% [95% CI: 0.60 to 0.74]). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography.

Conclusions:

Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.

Introduction

Appropriate use criteria (AUC) were launched to reduce heterogeneity of practice and to improve health service quality. Subsequently, AUC have also been considered as a method of controlling resource utilization and medical expenditures (1). This is especially true in cardiac imaging, where at 1 stage, the growth in costs was double the average annual growth of all services (2). Cardiology imaging reimbursements increased from US $1.6 billion in 2000 to US $5.1 billion in 2006 (3). However, after 2009, the volume of imaging has shown a decreasing trend (4). The initial AUC for single-photon emission computed tomography (SPECT) were followed by AUC for cardiac magnetic resonance (CMR), computed tomography angiography (CTA), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and stress echocardiography (5–10).

Whether the publication of AUC was the reason for the reduction in imaging is unclear. Evaluations after educational campaigns have shown heterogeneous responses (11–13). When changes have been reported, some papers have shown a reduction in the number of requests (11–14), and most have shown an improvement in the proportion of tests coded as being appropriate (13). The goal of the present study was to demonstrate the impact, if any, of AUC on the ordering behavior of clinicians by examining reported rates of appropriateness over time.

Methods

Search strategy

We adhered to the protocol specified in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for reporting systematic reviews (15). Two reviewers conducted a literature search of 5 online databases (Medline/PubMed, Scopus, Web of Science, Embase, and Cochrane) for published reports that estimated the proportion of appropriate tests using the AUC for cardiac imaging, including TTE, TEE, stress echocardiography, SPECT, CMR, and CTA for all years from 2005 through 2014. Papers were limited to those published in English. References of publications and relevant papers were also searched for further reports.

Inclusion criteria

Publications in peer-reviewed, English-language journals evaluating the AUC in TTE, TEE, stress echocardiography, SPECT, CMR, and CTA were included in this systematic review if they reported the following: 1) AUC used; 2) year of data collection; 3) sample size of tests evaluated; 4) proportion of appropriate imaging studies and proportion of uncertain or “rarely appropriate” tests; and 5) proportion of classified and/or unclassified tests. No restrictions were applied to the types of patients, the report’s country of origin or type of institution where the AUC were evaluated.

Outcomes

The primary outcome was the proportion of appropriate tests in the total sample of each report. The secondary outcome was the proportion of appropriate tests in classifiable imaging studies. For both, our goal was to determine the relation between appropriateness with median year of acquisition of the data and year of publication of the report. We also sought to assess the trends in classified imaging studies over time for each of the AUC editions.

Data extraction

Data were extracted by 1 review author (R.F.) and checked by a second reviewer (K.N.). Discrepancies between reviewers were resolved by consensus or, if necessary, by a third author (T.H.M.). Information on publication year, average of enrollment year, sample size, proportion of appropriate tests, sex, mean age, proportion of inpatient population, and specialty of physicians who requested the tests was extracted independently from every eligible report. If a paper reported the effect of intervention in the same population but at 2 points in time, both data points were used in 2 different analyses.

Because there were 2 editions of the AUC for each cardiac imaging test at the time of data extraction, analysis was performed in 10 groups: 2007 and 2011 TTE, 2007 and 2011 TEE, 2008 and 2011 stress echocardiography, 2005 and 2009 SPECT, and 2006 and 2010 CTA.

Statistical analysis

Meta-analysis was performed by using a logit transformation to calculate the weighted summary proportion under a random effects model (DerSimonian-Laird estimator). We assumed that effect sizes differed between reports due to differences in the characteristics of participants, between hospitals and regions, or protocols for using cardiac imaging in different scenarios. A random effect model was used because the differences in observed effects were not only due to sampling error.

Ten pooled analyses were conducted separately: 1 for each cardiac imaging and edition of AUC used (TTE 2007, TTE 2011, TEE 2007, TEE 2011, stress echocardiography 2008, stress echocardiography 2011, SPECT 2005, SPECT 2009, CTA 2006, and CTA 2010). Reports were included in >1 analysis if the report evaluated >1 cardiac imaging technique or a different edition of AUC. Heterogeneity among reports was assessed by using Cochrane’s Q test (reported with a chi-square value and p value) and was quantified with the I2 statistic. Potential sources of heterogeneity were investigated further by using meta-regression analysis. Meta-regressions were performed on the (nonlinear) logit scale; to show the effect of each report characteristic, the model coefficient at the mean of each characteristic was back-transformed. For characteristics that were proportion data (inpatients, male, specialists), we have shown the coefficient per 0.1 unit (or 10%) increase in proportion rather than the standard per 1-U increase. Publication bias was examined by plotting a funnel plot and was quantified by using Egger’s test.

All statistical analyses were performed by using R software version 3.1.0 (R Development Core Team 2013) with the following packages: “meta,” “metaphor,” and “boot.”

Results

Literature search

The initial search of the 5 online databases used in this work identified a total of 5,323 original papers (Online Figure 1). Exclusion of 5,264 papers after review of the title, abstract, or both left 59 possible papers suitable for the present systematic review. Some reports were used more than once if they had data for different cardiac imaging or the same imaging but different AUC edition. Of the reports included, 15 were used for the TTE 2007 analysis; 10 for TTE 2011; 5 for TEE 2007; 3 for TEE 2011; 6 for stress echocardiography 2008; 8 for stress echocardiography 2011; 11 for SPECT 2005; 11 for SPECT 2009; 9 for CTA 2006; and 7 for CTA 2010 analysis.

Characteristics of original reports

The majority of reports (53%) were retrospective in design (Online Table 1). An individual different from the ordering physician did the appropriateness scoring by using medical records, data, and requests of tests in ∼90% of reports. Among these reports in which reviewers scored appropriateness, 58% had the score reviewed only for unclassified tests or disagreement between reviewers. Physicians evaluated appropriateness in 51% of the reports; nurses or sonographers were reviewers in 15%; and the occupation of the reviewer was undefined in 34%. The weighted average of appropriate tests for physicians was 40% of the total sample (compared with 65% for nurses and 71% for sonographers).

In the majority of the papers, agreement between reviewers was not reported. In those papers in which reviewer agreement was reported, the agreement (kappa) between physician reviewers varied between 0.31 and 0.84. This range exceeded that for nurses (0.56 to 0.74) and sonographers (0.67 and 0.84). The observations were based on the request at the point-of-service in 86%. Most (73%) were performed in an academic setting, with 13.6% in a community setting and 13.6% in both environments. Tables 1 and 2 present the papers included for each of the analyses.

Table 1. Overview of Reports Included in the TTE and TEE Analyses

First Author (Ref. #)TestAUC EditionPublication YearEnrollment YearnApp TestApp (%)Classified Imaging StudiesPrevious Echo (%)Inpatient (%)Age (yrs)WomenCardiac Specialist (%)
Ward et al. (23)TTE2007200820071,5531,2280.791,3850.360.4858.8 ± 16.90.530.48
Willens et al. (24)TTE2007200920086254810.775260.170.22
Dharmarajan et al. (25)TTE20072009200358510.885829.0 ± 6.01.000.19
Kirkpatrick et al. (26)TTE2007200920073682060.562370.780.0055.0 ± 17.00.510.61
Martin and Picard (27)TTE2007200920082742370.862681.000.500.38
Bhave et al. (21)TTE2007201020092581990.772210.3559.0 ± 18.00.530.55
Rao et al. (28)TTE2007201020087725330.697160.001.00
Aggarwal et al. (29)TTE2007201020073292780.842990.4463.0 ± 15.00.420.57
Ghatak et al. (30)TTE2007201120094313640.84394
Rahimi et al., 1 (16)TTE2007201120001771430.811640.370.0053.0 ± 17.00.270.37
Rahimi et al., 2 (16)TTE2007201120083482510.722960.540.0058.0 ± 17.00.480.37
Parikh et al. (31)TTE2007201220103843330.873360.310.6864.0 ± 16.00.450.51
Bhatia et al. (32)TTE2007201220114502880.643470.690.3370.6 ± 14.70.500.38
Alqarqaz et al. (33)TTE2007201220091701310.771470.40
Silverman et al. (34)TTE2007201220094854420.914850.50
Bailey et al. (35)TTE2007201320081,0809330.869451.0071.2 ± 15.00.10
Willens et al. (36)TTE2011201120086254790.776170.170.22
Parikh et al. (31)TTE2011201220103843540.923630.310.6864.0 ± 16.00.450.51
Bhatia et al., 1 (32)TTE2011201220114503130.694410.690.3370.6 ± 14.70.500.38
Patil et al. (37)TTE2011201220101,8201,4930.821,8120.47
Alqarqaz et al. (33)TTE2011201220091701310.771700.40
Ballo et al. (38)TTE2011201220109317390.7992072.8 ± 14.40.460.49
Mansour et al. (39)TTE2011201220071,5531,2530.811,5250.4959.0 ± 17.00.520.50
Bailey et al. (35)TTE2011201320081,0801,0420.961,0801.0071.2 ± 15.00.10
Matulevicius et al. (40)TTE2011201320115354910.925350.570.590.31
Bhatia et al., 2 (11)TTE2011201320111,3181,1050.841,31263.00.46
Bhatia et al., 3 (11)TTE2011201320123453120.9033761.00.42
Rao et al. (41)TEE2007200920061,2351,1560.941,23561.0
Aggarwal et al. (29)TEE2007201020072001910.951940.5063.0 ± 15.00.420.57
Ogbara et al. (42)TEE2007201120113893210.82389
Bhatia et al. (43)TEE2007201220112021560.771660.7663.0 ± 14.00.200.73
Mansour et al. (39)TEE2007201220074053580.883680.7259.0 ± 17.00.520.50
Bhatia et al. (43)TEE2011201220112021900.941990.7663.0 ± 14.00.200.73
Grewal et al. (44)TEE2011201220086716390.9565966.0 ± 13.00.33
Mansour et al. (39)TEE2011201220074053820.944040.7259.0 ± 17.00.520.50

App = appropriate; AUC = appropriate use criteria; Echo = echocardiography; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.

∗ Values are mean ± SD or mean.

Table 2. Overview of Reports Included in the SE, SPECT, and CTA Analyses

First Author (Ref. #)Imaging TestAUC EditionPublication
Year
Enrollment YearnApp TestsApp (%)Classified Imaging StudiesPrevious Echo (%)Inpatient (%)Age (yrs)Female (%)Cardiac Specialist (%)
McCully et al. (45)SE2008200920052981595324166.0 ± 13.048
Mansour et al. (46)SE20082010200828918062253759.0 ± 18.04945
Bhatia et al. (47)SE200820132011252104411261558.1 ± 12.24250
Willens et al. (12)SE20082013200820910450189056.1 ± 13.85352
Lin et al. (48)SE20082013201011150459251.454
Schmitz et al. (49)SE20082013201030019465226
Mansour et al. (39)SE20112012200828916557281759.0 ± 17.05250
Cortigiani et al. (50)SE2011201220031,552984631,5520
Bhatia et al. (47)SE201120132011252105422211558.1 ± 12.24250
Bhattacharyya et al. (51)SE2011201320111004949100
Willens et al., 1 (12)SE20112013200820910048207056.1 ± 13.85352
Willens et al., 2 (12)SE2011201320112098239200056.3 ± 14.75353
Willens et al., 3 (12)SE2011201320011114843107057.7 ± 13.350100
Schmitz et al. (49)SE201120132010300300100300
Gibbons et al., 1 (52)SPECT2005200820052841826425367.0 ± 11.037
Mehta et al. (53)SPECT2005200820061,209940781,1735569
Hendel et al. (54)SPECT2005201020076,3514,192665,90665.7 ± 11.84175
Gibbons et al., 2 (55)SPECT2005201020062841886624168.0 ± 11.033
Carryer et al. (56)SPECT2005201020052811796425067.0 ± 11.037
Gupta et al. (57)SPECT2005201120093142638431462.0 ± 14.04862
Gibbons et al., 3 (13)SPECT2005201120082731646023265.0 ± 13.033
Gholamrezanezhad et al. (58)SPECT2005201120092912117227955.3 ± 10.357
Druz et al. (59)SPECT200520112007585370635704863.5 ± 13.14544
Soine et al., 1 (17)SPECT2005201220071,377950691,37758.4 ± 13.452
Soine et al., 2 (17)SPECT2005201220071,4451,286891,44560.8 ± 10.69
Carryer et al. (56)SPECT2009201020052811686028167.0 ± 11.037
Koh et al. (60)SPECT2009201120091,6231,331821,57461.0 ± 11.03993
Gholamrezanezhad et al. (58)SPECT2009201120092912197528355.3 ± 10.357
Nelson et al., 1 (18)SPECT200920122009150101671481261.0 ± 10.01
Nelson et al., 2 (18)SPECT2009201220091501117415065.0 ± 12.04347
Koh et al. (61)SPECT2009201220091761066017661.0 ± 11.041
Lin et al. (48)SPECT2009201320103381785331257.334100
Winchester et al. (62)SPECT200920132011332259783284
Doukky et al. (63)SPECT2009201320091511779521,49159.0 ± 13.043
Moralidis et al. (64)SPECT2009201320113,0322,208733,00866.0 ± 11.041
Aldweib et al. (65)SPECT2009201320061,199740621,1943663.8 ± 12.544
Ayyad et al., 1 (19)CTA2006200920067635306971557.2 ± 13.635
Ayyad et al., 2 (19)CTA2006200920076465077862358.1 ± 13.335
Miller et al. (66)CTA2006201020072516927136
Murphy et al. (67)CTA200620102008267126471896956.2 ± 14.03682
El Sibai et al. (68)CTA200620112009100881001953.0 ± 13.01777
Chinnaiyan et al. (69)CTA20062012200925,3875,0532012,8532757.04621
Rich et al. (70)CTA2006201220111,216503411,0693157.5 ± 15.747
Mazimba et al. (71)CTA200620122007243361524359.2 ± 12.355
Wasfy et al. (72)CTA200620122008267119451895156.2 ± 14.036
El Sibai et al. (68)CTA20102011200910038381001953.0 ± 13.01777
Chinnaiyan et al. (69)CTA20102012200925,38718,2667222,4422757.04621
Rich et al. (70)CTA2010201220111,216863711,1593157.5 ± 15.747
Mazimba et al. (71)CTA2010201220072431194924359.2 ± 12.355
Wasfy et al. (72)CTA201020122008267157592315156.2 ± 1436
Lin et al. (48)CTA2010201320102313561850.339
Cullen et al. (73)CTA2010201320072518534212

CTA = computed tomography angiography; SE = stress echocardiography; SPECT = single-photon emission computed tomography; other abbreviation as in Table 1.

∗ Values are mean ± SD or mean.

Publication bias

Funnel plots were made for each of the pooled analyses (Online Figure 2). There was evidence of publication bias for stress echocardiography 2011 (p = 0.01) and CTA 2010 (p = 0.02). However, bias was not identified for TTE 2007 (p = 0.24), TTE 2011 (p = 0.10), TEE 2007 (p = 0.99), TEE 2011 (p = 0.39), stress echocardiography 2008 (p = 0.65), SPECT 2005 (p = 0.35), SPECT 2009 (p = 0.93), or CTA 2006 (p = 0.08).

Temporal changes in appropriate use

New versions of AUC were associated with apparent improvements in appropriateness for TTE, TEE, and CTA but not for stress echocardiography or SPECT (Central Illustration). The only modality showing a correlation between the proportion of appropriate testing and published year was for TTE, using the 2011 guidelines.

Central Illustration.
Central Illustration.

Reported Appropriate Use in Papers Applying Different Versions of Appropriate Use Criteria

Each line represents a summary of overall estimates calculated from random effect models of proportion of appropriate tests. Individual Forest plots are provided in the online figures (y-axis: appropriate use criteria edition; x-axis: 95% confidence intervals [CI]). CTA = computed tomography angiography; SE = stress echocardiography; SPECT = single-photon emission computed tomography; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.

TTE (2007 edition)

Of the 15 reports in which the AUC for TTE was evaluated by using the 2007 edition, 1 paper (16) was presented twice because it analyzed 2 different samples for TTE at 2 different points of time (Table 1, Online Figure 3). Thus, there are 16 different rows (n = 7,762 TTE) analyzed for 15 different reports published between 2008 and 2013, with a range of enrollment between 2000 and 2011. The pooled proportion of appropriateness of the total sample was 0.80 (95% CI: 0.75 to 0.84), with substantial heterogeneity among the estimates (I2 = 95.4%, p < 0.0001). The weighted average of appropriate tests among classifiable imaging studies was 0.91 (95% CI: 0.87 to 0.93) (Table 3). Heterogeneity was explored by using the following factors: publication year, sex, proportion of inpatients, and proportion of tests ordered by cardiologists. In univariate meta-regression, there was no significant association of proportion of appropriate tests with publication year (p = 0.36) (Table 4). In addition, there were no significant relations between appropriateness and sex, type of patient, or cardiologist who ordered the test. However, there was a positive association between proportion of appropriate testing and proportion of inpatients (p = 0.0006). The proportion of classifiable imaging studies showed no significant improvement over time (Table 3).

Table 3. Proportion of Appropriate Tests and Their Association With Publication Year in the Total Sample and Among Classifiable Imaging Studies and Examination of the Association Between the Proportion of Classifiable Tests and Publication Years

Total SampleClassified Studies% Classified Studies of Total Sample
% AppropriatePublication Yearp Value% AppropriatePublication Yearp Value% ClassifiedPublication Yearp Value
TTE 200780 [75–84]0.090.3691 [87–93]0.260.0689 [85–92]−0.020.87
TTE 201185 [81–89]0.730.0187 [83–90]0.690.0799 [98–99]0.670.24
TEE 200789 [81–94]−0.430.0395 [89–97]−0.010.9897 [91–99]−1.540.03
TEE 201195 [93–96]96 [94–97]99 [97–99]
SE 200853 [45–61]−0.070.4671 [60–80]0.050.8080 [67–89]−0.120.57
SE 201152 [42–61]−0.040.9753 [44–61]−1.420.3598 [95–99]−1.420.35
SPECT 200572 [66–77]0.100.4076 [71–80]0.040.7095 [92–97]0.840.05
SPECT 200968 [60–74]−0.120.4269 [71–76]−0.130.4299 [97–99]−0.010.99
CTA 200637 [21–55]−0.590.0248 [35–62]−0.570.0587 [74–94]−0.090.87
CTA 201055 [44–65]−0.060.8961 [47–74]0.160.7690 [85–94]−1.410.03

Values in brackets are 95% confidence intervals.

Abbreviations as in Tables 1 and 2.

∗ Regression coefficient (slope).

Table 4. Meta-Regression of the Associations of the Proportion of Appropriate Tests

Publication Yearp ValueMalep ValueCardiologistsp ValueInpatientp ValueAgep Value
TTE 20070.090.36−0.620.64−1.030.101.10<0.01−0.010.67
TTE 20110.730.01−0.021.00−2.590.223.04<0.010.000.99
TEE 2007−0.430.03−3.420.42−4.810.42−6.340.01−0.010.97
TEE 20110.160.880.160.880.160.880.030.51
SE 2008−0.070.46−1.630.68−8.870.240.030.46
SE 2011−0.040.97−2.030.56−0.320.694.710.510.130.25
SPECT 20050.100.401.180.640.960.71−0.010.16
SPECT 2009−0.120.420.390.69−0.760.750.010.77
CTA 2006−0.590.02−0.021.000.490.8917.53<0.010.280.28
CTA 2010−0.060.89−2.420.1911.690.020.010.45

Abbreviations as in Tables 1 and 2.

∗ Regression coefficient (slope).

TTE (2011 edition)

Ten reports using the 2011 edition of the AUC for TTE were analyzed (n = 9,211). Because 1 paper (11) was divided into 2, there were 11 reports included in this analysis. The weighted proportion of appropriate tests was 0.85, with substantial heterogeneity among the estimates (95% CI: 0.81 to 0.89; I2 = 96.2%, p < 0.0001) (Online Figure 3). In this group, a significant positive association was found between appropriateness and year of publication (p = 0.01), as well as a strong positive association between inpatient status and appropriateness in the total sample (p < 0.0001) (Table 4). There was no improvement in the proportion of appropriate tests among classifiable imaging studies over time (Table 3).

Transesophageal echocardiography

Five reports based on the TEE 2007 AUC (n = 2,431) were published between 2009 and 2012 (Online Figure 4). The weighted proportion of appropriate tests was 0.89, with substantial heterogeneity among estimates (95% CI: 0.81 to 0.94; I2 = 94.8%, p < 0.0001). In the overall sample, there was a negative association between appropriateness, publication year (p = 0.03), and inpatients (p = 0.007) (Table 4). There were no significant associations between appropriateness and sex, ordering physician, or age. There was an apparent correlation between proportion of classified imaging studies and publication year (Table 3). Three papers used TEE 2011 AUC, which included 1,278 tests. There was no association with time, sex, specialists, or type of patients.

Stress echocardiography

The 2008 AUC were used in 6 reports (n = 1,459) of stress echocardiography published between 2009 and 2013, with enrollment data between 2005 and 2011. The pooled appropriate testing proportion using the 2008 AUC was 0.53, with significant heterogeneity between estimates (95% CI: 0.45 to 0.61; I2 = 88.3%, p < 0.0001) (Online Figure 5). There were no significant associations between proportion of appropriateness and publication year, sex, or specialists for either all imaging studies or classifiable studies (Tables 3 and 4).

For the analysis of the AUC 2011 for stress echocardiography, 1 report (12) was divided into 3. Thus, 8 papers with a total of 3,022 tests were included (Online Figure 5). The average appropriateness was 0.52 (95% CI: 0.42 to 0.61; I2 = 93.7% p < 0.0001). No significant associations between appropriateness and publication year, sex, or specialists were found (Table 4) either among all imaging studies or classifiable studies (Table 3).

Single-photon emission computed tomography

Ten reports used the 2005 AUC version for SPECT, with 1 report (17) divided in 2, resulting in 11 reports (n = 12,694 tests). The weighted proportion of appropriate tests was 0.72 (95% CI: 0.66 to 0.77; I2 = 97.2%, p < 0.0001) (Online Figure 6). No significant associations between appropriateness and publication year, sex, or specialists were found (Table 4). Using the 2009 AUC edition for SPECT, 10 reports were found (n = 9,083 tests), with 1 report (18) divided in 2. The weighted proportion of appropriate tests was 0.68 (95% CI: 0.60 to 0.74; I2 = 97.8%, p < 0.0001). No significant associations between appropriateness and publication year, sex, or specialists were found.

Computed tomography angiography

Eight reports (n = 29,140) were found evaluating the 2006 AUC for CTA, with 1 report (19) divided in 2. The average of appropriateness was 0.37 (95% CI: 0.21 to 0.55; I2 = 99.6%, p < 0.0001) (Online Figure 7). A drop in the proportion of appropriate tests in relation to the year of publication of the paper was found (p = 0.02) (Table 4). No significant associations between appropriateness and sex or specialists were identified. However, a strong positive association between proportion of appropriateness and inpatients was found (p < 0.0001).

For the evaluation of the 2010 AUC for CTA, 7 reports included 27,487 tests (Online Figure 7). The weighted proportion of appropriate tests was 0.55 (95% CI: 0.44 to 0.65; I2 = 97.8%, p < 0.0001). Only a significant association between appropriateness and inpatient tests was found (p = 0.0206) (Table 4). There was a significant diminution of classified reports in relation to publication year (Table 3).

“Rarely” and “Maybe” appropriate tests

Tables 5 and 6 present the proportion of “rarely appropriate” and “maybe appropriate” tests, respectively, and their association with the publication year in the total sample and among classifiable imaging studies. There was a significant diminution of “rarely appropriate” tests in the 2007 TEE AUC with time. However, no such improvement has been noted with the new edition. There was no impact of the AUC in “rarely appropriate” tests for other cardiac imaging modalities. Between the old and new editions, “rarely appropriate” stress echocardiography studies increased from 18% to 27%, SPECT from 11% to 20%, and CTA from 17% to 21%.

Table 5. Meta-Regression of Proportion of “Rarely Appropriate” Tests of Total Sample and Classified Studies as Dependent Variables

Total SampleClassified Studies
% “Rarely Appropriate”Publication Yearp Value% “Rarely Appropriate”Publication Yearp Value
TTE 20078 [6–11]−0.250.069 [7–13]−0.260.06
TTE 20119 [6–12]−0.630.099 [7–12]−0.640.08
TEE 20071 [1–3]−0.450.001 [1–3]−0.430.001
TEE 20112 [2–4]3 [2–4]
SE 200818 [11–27]−0.030.9123 [16–32]0.020.92
SE 201127 [22–33]0.100.8328 [22–35]0.020.97
SPECT 200511 [9–14]−0.130.2812 [10–14]−0.150.21
SPECT 200920 [14–28]0.050.8120 [14–28]0.050.78
CTA 200617 [12–23]0.400.0921 [13–33]0.450.05
CTA 201021 [11–37]−0.550.430.23 [0.12–0.39]−0.400.56

Values in brackets are 95% confidence intervals.

Abbreviations as in Tables 1 and 2.

∗ Regression coefficient (slope).

Table 6. Meta-Regression of Proportion of “May Be Appropriate” Tests of Total Sample and Classified Studies as Dependent Variables

Total SampleClassified Studies
% May Be AppropriatePublication Yearp Value% May Be AppropriatePublication Yearp Value
TTE 2007
TTE 20114 [3–6]−0.840.054 [3–6]−0.840.04
TEE 2007
TEE 20111 [0–3]1 [0–3]
SE 20086 [3–9]−0.280.268 [5–12]−0.220.31
SE 201115 [9–24]0.020.9816 [10–24]0.070.95
SPECT 200511 [9–14]0.090.3512 [10–15]0.070.50
SPECT 20098 [5–13]0.060.819 [5–14]0.070.80
CTA 200619 [12–29]0.260.1724 [18–31]0.310.01
CTA 20100.11 [8–16]0.120.7812 [9–17]0.240.59

Values in brackets are 95% confidence intervals.

Abbreviations as in Tables 1 and 2.

∗ Regression coefficient (slope).

TEE 2007 showed a decrease over time in the tests that were “maybe appropriate” (beta = –0.84, p = 0.04). CTA 2006 showed an increase in the proportion of “maybe appropriate” tests of classified imaging studies, but not of the total sample, over time (beta = 0.31, p = 0.01). No other improvements in the tests considered “maybe appropriate” were found for the remaining modalities.

Discussion

This comprehensive evaluation of published data evaluated AUC for different cardiac imaging techniques from 103,567 tests grouped in 10 different cardiac imaging outcomes. Meta-regression was used to evaluate the temporal trend of appropriateness, based on the year of publication. In contrast to reports comparing the behavior of specific groups of physicians over time, the results are an indication of “real-world” practice at sites publishing their appropriate use data. There are 5 important observations. First, the improvement of appropriate use from the original to the revised versions may merely reflect easier classification of patients and a change in attribution of proportion of appropriate testing rather than a change in practice. Second, we found a temporal improvement in percent appropriateness for TTE, TEE, and CTA, but no evidence of a change in the number and proportion of appropriate testing for other modalities. Overall rates of appropriate use for CTA and stress echocardiography remain low, and those for SPECT are only modest. This implies a disconnection between clinical practice and AUC that warrants better understanding. Third, this limited change has not matched the reduction in imaging tests over the last 5 years, suggesting that physician use of AUC in the ordering process may not have played a major role in this reduction. However, an indirect role (through AUC influence on the decisions of radiology benefit managers) cannot be excluded. Fourth, the proportion of appropriate use presented here may well be shown to its advantage in these retrospective and largely unblinded evaluations, which for the most part were performed by physicians able to identify appropriate indications, even if this was not the primary reason for the test. Moreover, the evaluations were mainly performed at the point of service of academic medical institutions. There was substantial variation between observers, especially between physicians. Finally, although there was some evidence of publication bias for stress echocardiography 2011 and CTA 2010, bias was not identified for most scenarios.

Understanding temporal variations in appropriateness

The observed heterogeneity of the proportion of appropriate testing among reports might be expected on the basis of a wide variety of participant characteristics, study designs, and types of hospital and regions in the published data. However, the unique aspect of this work is its examination of the temporal variation in proportion of appropriate testing.

The drivers of test ordering are complex, and the persistent rate of ∼80% for TTE (and less for other modalities) perhaps testifies to a variety of influences that are not disease specific. These include factors individual to the patient, such as factors related to other comorbidities and situational considerations. These features may drive the request for testing in a situation when the test is considered “rarely appropriate” and explain the stability of this attribution. In addition, clinical practice guidelines may be discordant with AUC. Finally, the adjudication of appropriate testing is often inconsistent because appropriate and “rarely appropriate” reasons for testing may coexist in the same patient. The implication is that the ordering physician may choose an existing appropriate indication rather than the real clinical issue. This may be likely when the proportion of inappropriate (or “rarely appropriate”) tests is reviewed as part of the accreditation process (20).

In this respect, the increment of “rarely appropriate” tests from the first to the second versions of stress echocardiography, SPECT, and CTA was a surprising finding of this meta-analysis. Interestingly, none of these tests showed a gradation of “rarely appropriate” use within the time frame of each edition; therefore, this finding likely reflects the change in criteria rather than a change in practice.

Alternative approaches to reducing cost

The use of AUC as a process to reduce costs neglects the fact that testing labeled as “sometimes” and “rarely appropriate” is very reasonable in some situations. Indeed, this is a shortcoming of the widespread use of radiology benefit managers as a tool to control the use of cardiac imaging: they are inflexible to situational demands (12). The application of AUC at the point of care (e.g., using electronic tools that help physicians to choose “appropriately”) has produced similar results to the radiology benefit managers but has the same limitation (21).

Although the nuances of specific clinical scenarios make the AUC problematic for controlling testing, they are potentially valuable as a yardstick for education. The evidence available regarding the value of educational campaigns is contradictory (11–13). In the interpretation of responses to AUC campaigns, it should be noted that knowledge of AUC is only 1 component of test selection. Test selection is also influenced by the characteristics of health professionals, features of practice settings, incentives, linkage of AUC performance with accreditation or licensing bodies, patient factors, compatibility with existing practice and beliefs, and perceived quality of the guidelines (22). Moreover, how much repetition is required for an educational campaign to have a sustained effect is unclear.

In jurisdictions in which the laboratory is responsible for appropriate use, a strategy of laboratory-based audit is needed for the thousands of cardiac imaging requests that are submitted to the laboratory every year. The use of AUC to facilitate auditing is more likely to be effective than its application to individual test requests. Tests that are most likely to be of “maybe” or “rare” appropriateness include those requested in younger patients, those with previous tests, those who are outpatients, or tests that are reevaluations in patients who are asymptomatic or have no changes in clinical status (23). These situations might be used as markers of potential inappropriate use in individual patients.

Study limitations

Most cardiovascular imaging is performed in the community practice environment, whereas most AUC reports have been reported in academic medical centers. Nonetheless, the wide discussion of AUC over the last decade might be expected to influence all environments, and a practice-specific variation of some tests and not others seems unlikely. It is unclear whether changes in percent appropriateness reflect better test selection rather than observer-expectancy effect or coding of indications to satisfy AUC.

Conclusions

Improvements in the percent appropriateness rate of TTE seemed to correlate with the temporal reduction in imaging. However, methodological problems in these published reports (including possible publication bias and retrospective assignment of AUC ratings in most reports by individuals affiliated with the institution where the analysis was performed) may compromise confidence in this observation. Moreover, these changes are not uniform. There were no positive associations between the rate of appropriateness and date of publication for SPECT, TEE, CTA, and stress echocardiography. It is possible that the reduction of imaging tests is unrelated to AUC.

Perspectives

COMPETENCY IN SYSTEMS-BASED PRACTICE: Appropriate use of echocardiography (TTE and TEE) ranges from 80% to 90%, whereas adherence to current AUC for noninvasive assessment of coronary disease ranges from 50% for stress echocardiography and CTA to ∼70% for radionuclide (SPECT) imaging. Over a 5-year period, there was improvement in appropriate use of TTE, TEE, and CTA, but no change in the proportion of appropriate use of the other modalities.

TRANSLATIONAL OUTLOOK: The apparent discordance between AUC and clinical practice patterns suggests that more objective methods are needed to assess the appropriateness of diagnostic imaging procedures.

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Abbreviations and Acronyms

AUC

appropriate use criteria

CMR

cardiac magnetic resonance

CTA

computed tomography angiography

TEE

transesophageal echocardiography

TTE

transthoracic echocardiography

SPECT

single-photon emission computed tomography

Footnotes

Dr. Fonseca is supported by a scholarship from the Farrell Foundation. Dr. Negishi is supported by an award from the Select Foundation, Hobart, Australia. Dr. Marwick has received research grants from GE Medical Systems and Siemens. Mr. Otahal has reported that he has no relationships relevant to the contents of this paper to disclose.

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