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Did Appropriate Use Criteria Hit Heart Scan?

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Did the emergence of appropriate use criteria for imaging help bring about the downfall of—or at least a sharp decline in—nuclear myocardial perfusion imaging (MPI)?

A research letter in JAMA last week reported that, “After increasing from 2000 to 2006, MPI abruptly declined through 2011.” Why? The letter didn’t really come up with an answer.

The researchers studied the rise and fall of MPI at Kaiser Permanente Northern California, which provides health care for more than 2.3 million adults. Lead author Edward J. McNulty, MD, is an interventional cardiologist at Kaiser Permanente San Francisco Medical Center.

The study did conclude that “the abrupt nature of the decline suggests changing physician behavior.” In an e-mail interview with MedPage Today, Dr. McNulty elaborated:

The fact that we observed greater declines amongst lower-risk subsets (outpatients and younger persons) suggests MPI use became more discriminating (used preferentially in higher-risk persons).

Specifically, the study found that MPI use increased by 41 percent from 2000 until 2006. But from 2006 through 2011, it declined by 51 percent. The use of cardiac CT scans increased from 2006 through 2011, but the researchers found that this modality substitution could have accounted for only about 5 percent of the MPI decline.

The researchers noted that the rate of heart attacks (incident myocardial infarctions), which they used as a measure of coronary disease, also declined by 27 percent from 2006 through 2011. That also undoubtedly had something to do with the MPI decline.

The study concludes, “We could not determine the relative effects of these factors on MPI use.”

However, as Dr. McNulty told MedPage Today, “More recently, factors potentially discouraging use, such as appropriate use criteria, declining reimbursement, radiology benefits managers, and more publicized concerns about the health effects of radiation, have emerged.”

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