Appropriate Use Criteria for Stress Single-Photon Emission Computed Tomography Sestamibi Studies: A Quality Improvement Project

OBJECTIVES: We previously reported the application of the 2005 American College of Cardiology Foundation appropriate use criteria for stress single-photon emission computed tomography (SPECT) imaging to patients at Mayo Clinic (Rochester, MN) in 2005 and 2006. A subsequent internal quality improvement project focused on physician education in an attempt to reduce the rate of inappropriate SPECT studies.

METHODS: Our 2008 physician education effort, focused on 4 specific indications that accounted for 88% of the inappropriate SPECT studies, included a presentation at medical grand rounds, a publication in the staff newsletter, meetings with physician administrators, and focused presentations to departments/divisions with many ordering physicians. We then remeasured the appropriateness of SPECT studies using previously published methods.

RESULTS: The general categories of study indications, eg, after revascularization, were similar in 273 SPECT patients in 2008 and in our 2005 (n=284) and 2006 (n=284) cohorts. There was a trend suggesting a change in the overall classification of appropriateness over time (P=0.08) and a significant change in the rate of inappropriate studies over time (P=0.018). Inappropriate studies decreased from 14.4% in 2005 to 7.0% in 2006 before initiation of the quality improvement project. After completion of the quality improvement project, inappropriate studies increased to 11.7% (P=0.06). The 95% confidence limits for the 4.7% increase in inappropriate studies after the quality improvement project included a decrease of 0.2% and an increase of 9.6%.

CONCLUSIONS: This quality improvement project, focused on feedback, physician education, and remeasurement, did not reduce the rate of inappropriate stress SPECT studies in a single academic medical center. Similar limited interventions focused on physician education alone may have limited benefit. More extensive intervention may be necessary to improve the quality of care with appropriateness criteria. 

PMID: 21262995

Posted in Nuclear Imaging and tagged , .


  1. This is another of Gibbons papers attempting to study appropriateness criteria. It should be thought of as a study of the appropriateness criteria themselves. Early reviewers didn’t understand that and so the early papers that Gibbons published were usually in smaller journals. Now this type of paper made it to Circulation.

    You’ll see that physician feedback and education didn’t decrease the rate of inappropriate exams, which doesn’t surprise me all that much.

  2. Very interesting paper!
    I have also read papers that cited under utilization of SPECT referral for patients that meet criteria, but because of a lack of clear understanding of guidelines never receive the recommendation.

  3. An important study, and the take home message is clear: From a clinician point of view I believe that 1) Quality improvement interventions are still important and probably worth the effort, even if the “quantity” didn’t change. 2) Inappropriate indications are considered appropriate by others as there is no substitution for clinical judgment, and therefore inappropriate indications do not necessarily translate to “bad practice” in a given patient.
    I remember that Dr. Araoz and colleagues showed similar results lately for CT-see the link for the article below.

    Evaluation of coronary CTA Appropriateness Criteria in an academic medical center.
    Miller JA, Raichlin E, Williamson EE, McCully RB, Pellikka PA, Hodge DO, Miller TD, Gibbons RJ, Araoz PA.
    J Am Coll Radiol. 2010;7(2):125-31.

  4. The criteria of inappropriate indications changes every year. All that cardilogists have done before are inappropriate indications for the next year’s guidelines.
    However, radiation exposure of SPECT is much lowever than PCI, CCTA, or X- ray.

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