Nuclear cardiology in its over 40 years of use has grown to one of the most utilized and performed medical procedures in the United States, with cardiovascular imaging tests frequently being listed among the top 200 Medicare expenditures.1–3 As nuclear cardiology has blossomed into an over $1 billion per year industry, increased attention and scrutiny have been given to this testing approach, particularly with cost-effectiveness playing a more central role. This has been seen in several different ways. Appropriate use criteria (AUC) have become mainstream tools in providing decision-making support as to whether or not a test or procedure is indicated based on evidence combined with expert consensus opinion.4–6 This has contributed to a downtrend in the number of nuclear stress tests performed annually over the last decade (Fig. 20-1).7 In addition, in an era with continued technological advancements in each of the cardiac imaging modalities, clinicians often have multiple testing options that can be performed for a particular patient prompting a decision process that necessitates the evaluation of cost-effectiveness.6,8
Age- and sex-adjusted annual rates of nuclear myocardial perfusion imaging tests from 2000 to 2011 showing initial increase in volume up until 2006 followed by a steady decrease in test performance. (Reproduced with permission from McNulty EJ, Hung YY, Almers LM, et al. Population trends from 2000–2011 in nuclear myocardial perfusion imaging use. JAMA. 2014;311(12):1248–1249.)
Since 2005, which reflected the peak years of nuclear cardiology reimbursement, there have been increased restrictions on referrals for diagnostic testing including preauthorization and test substitution, as well as reductions in reimbursement for location of testing performed (outpatient vs. hospital based). In addition, the Institute of Medicine in 2009 suggested that 30% or $750 billion per year was spent on unnecessary medical services,9 which puts all procedures under scrutiny. As the value of an imaging study becomes a pivotal issue, every diagnostic test must now pass individually defined quality and efficiency criteria. The value of the imaging study must balance the cost of the procedure with its impact on changing patient treatment and influencing outcomes. As the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is implemented, the net value of the imaging procedure will directly impact on levels of reimbursement.
Thus, as the cost of diagnostic testing now plays a greater role in clinical decision making, clinicians have to be well educated in the science and economics of medicine as it impacts their daily practice. This chapter will discuss approaches to optimize the efficiency and quality of care based on patient selection for testing. This will be followed by a review of the definitions currently used for analysis and determination of cost-effectiveness. Finally, we will discuss sentinel studies that have examined value-based comparative approaches to diagnostic testing using nuclear stress tests as ...