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KEY POINTS
The appropriate use criteria (AUC) were created to improve quality care and avoid misuse of medical technology.
AUC are literature-based whenever possible, supplemented by consensus recommendations when data are lacking.
AUC serve as methods for focused reduction of procedures based upon clinical value, not indiscriminant volume reduction.
For symptomatic patients, AUC for nuclear cardiology procedures are based upon pretest likelihood of disease, exercise ability, and ECG interpretability.
Among asymptomatic patients who have undergone revascularization, only those with incomplete revascularization should be tested or if completely revascularizated 2 years after percutaneous coronary intervention or 5 years following coronary artery bypass graft surgery.
For preoperative assessment, testing is indicated only for high-risk surgery in patients with poor or unknown functional capacity who also have ≥1 risk factor.
AUC support clinical decision support tools and are often included in regulatory and/or reimbursement policies.
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There has been substantial evolution and innovation in cardiovascular imaging during the last several decades. Notably, the improvement in the detection of coronary artery disease (CAD) and the delineation of cardiomyopathies has led to earlier management decisions, leading to improved outcomes.1,2 Nuclear cardiology, including single-photon emission computed tomography (SPECT) and positron emission tomography (PET) myocardial perfusion imaging (MPI), remains critical for accurate diagnosis and risk stratification of patients with either known or suspected CAD, thereby enabling accurate medical decision making.
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The dramatic increase in the use of SPECT and PET MPI studies, which while providing benefit to a substantial number of patients, has raised concerns about the possible overuse/misuse of this technology to contribute to the spiraling economic burden of health care. Furthermore, there is an additional risk of unnecessary testing, by exposing patients to ionizing radiation and potential unjustified therapeutic interventions, without a real impact on patient health.3
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The Medicare Payment Advisory Commission (Med-PAC) reported medical diagnostic imaging rate between 1999 and 2002 annually increased to 10.1% during this period,4 which far exceeded the increased rate for other medical charges. Estimates suggested that as much as 30% of diagnostic testing in the United States was unnecessary.5 Additionally, there was a lack of transparency indicating a possible financial motivation on the provider’s part. In 2014, Medicare spending on advanced imaging was over $4 billion,6 the costs are even greater when accounting for additional therapeutic and follow-up care. The findings were attributed to the nonuniform distribution of specialized imaging centers, referral practice patterns, and unclear guidelines recommendations. It led to an important adjustment in the US healthcare system with a shift in the emphasis from volume to value, with value defined as the outcome achieved per dollar spent.7 Initial efforts to control healthcare costs included payers using radiology benefits management (RBM) companies to act as governors for the exponential growth and cost of imaging.2 The RBM’s sought to reduce imaging volume and thereby cost to the insurance company by using techniques such as exclusion ...