Evaluation of Coronary CTA Appropriateness Criteria in an Academic Medical Center
OBJECTIVES: The aim of this study was to evaluate published appropriateness criteria for CT angiography (CTA) at the authors’ academic medical center.
METHODS: Two observers independently reviewed the medical records of 251 patients who had undergone dual-source coronary CTA from June 1 to December 31, 2007. Patients were assigned to indications from 1 of 7 tables from the American College of Cardiology Foundation and ACR Appropriateness Criteria. Agreement between the two observers was assessed using kappa statistics. Disagreements were resolved by consensus panel. The final numbers of appropriate, uncertain, inappropriate, and not classifiable indications were recorded.
RESULTS: Indications for testing were classified as appropriate in 69 patients (27%), inappropriate in 42 patients (17%), and uncertain in 25 patients (10%). One hundred fifteen indications for coronary CTA (46%) were not classifiable. Analysis of interobserver variability for overall appropriateness yielded a kappa value of 0.31, which was considered to indicate fair agreement.
CONCLUSION: The results of this study suggest that a significant proportion (46%) of the coronary CTA studies performed at the authors’ institution are for indications that are not covered by the published appropriateness criteria. Modifications to these criteria could help decrease the number of studies that are not classifiable. Physician education could decrease the number of inappropriate studies.
PMID: 20142087
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Ronen Rubinshtein, MD on February 17th, 2010
Interesting observation! It seems that patient’s needs and clinical judgment still lead to the use of coronary CT angiography even if indication is not found in published appropriateness criteria. Appropriateness criteria guidelines are wise recommendations, but can not cover all possible scenarios and clinical needs. While evidence based medicine is important, and guidelines are intended to assist physicians; the “inappropriate” of today may be the “appropriate” of tomorrow (and vice versa)…
Please also see an original call for evidence based medicine in cardiac CT:
Coronary artery imaging with multidetector computed tomography: a call for an evidence-based, multidisciplinary approach.
Schoenhagen P, Stillman AE, Garcia MJ, Halliburton SS, Tuzcu EM, Nissen SE, Modic MT, Lytle BW, Topol EJ, White RD.
Am Heart J 2006;151:945-948.
PMID: 16644309
Eric M. Dandes on February 17th, 2010
I agree with Dr. Rubinshtein.
Cardiac CT is the fastest growing imaging modality in cardiac imaging. However, the appropriate selection of patients for Cardiac CT has not been well established. Over the last 5 years, there are 3 guidelines that have been used for clinical indications and reimbursement: Regional Medicare (Empire NY/NJ), Local Coverage Determinants (LCD, L22380) and ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac CT.