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The past several decades have witnessed remarkable advances in medical care, including cardiac imaging. This rapid pace of technological development has provided a wealth of diagnostic and therapeutic tools that have impacted both quality and longevity of an individual's life.1,2 Particularly notable are the advances in cardiac imaging, which have revolutionized how patients are diagnosed and treated, enhancing the sensitivity and specificity for the detection of ischemic heart disease and related these results to patient outcomes, thereby resulting in an impact on survival and quality of life.
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However, the exuberance for nuclear cardiology, including single-photon emission tomography myocardial perfusion imaging (SPECT MPI) and positron emission tomography (PET), has resulted in a dramatic increase in its use and has contributed to the spiraling costs of health care cost.3,4 Furthermore, unnecessary testing may result in additional diagnostic tests and potentially unjustified therapeutic intervention, further escalating costs but also potentially impacting on patient health. Furthermore, the use of nuclear cardiology procedures exposes patients who do not need the testing to avoidable risks, as related to ionizing radiation and stress testing.
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The Medicare Payment Advisory Commission (Med-PAC) found that the rate of medical imaging between 1999 and 2002 far exceeded other medical services, with an annual increase by 10.1% during this time period (Fig. 13-1).2,4 Although it was concluded that no determination of inappropriateness was possible to be made due to lack of credible data,4 concern was raised as to the possible performance of unnecessary testing, which may have included financial motivation on the part of the providers. In addition to the excessive growth rate, SPECT/PET utilization demonstrated wide geographic variability across the United States, suggesting that differences in the volume of stress imaging procedures were unlikely a consequence of demographics or the prevalence of comorbid conditions alone,2,7 as these data were corrected for disease severity. Possible contributing factors included the nonuniform distribution of specialized imaging centers, self-referral practice at specific centers, and variances in the understanding of the medical literature.2
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Based on the concerns of overuse and misuse noted above, providers, regulators, and payers raised concern about overuse and misuse of radionuclide imaging, especially with regard to the negative economic consequences.2,5 In response to this and in an effort to reduce spending, health plans began to use radiology benefits management (RBM) companies to act as procedural governors by developing mechanisms to constrain the exponential growth of imaging and limit associated costs.2,3 The most common used programs ...