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

Purpose 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.
Methods 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.
Results 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 %).
Conclusion 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.