title: Appropriateness of referrals for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a developing community: a comparison between 2005 and 2009 versions of ACCF/ASNC appropriateness criteria.
abstract: BACKGROUND
  Appropriateness of referrals for myocardial perfusion imaging (MPI) in developing countries has not been extensively studied. Our study was conducted to describe the ordering practices of physicians and appropriateness of MPI referrals in Iran.
  
  
  METHODS
  We prospectively applied 2005 and 2009 versions of the Appropriateness Use Criteria published by the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) to 291 consecutive patients (age 55.3 ± 10.3 years) who underwent SPECT-MPI. For this purpose, we convened a panel, consisting of two academic cardiologists, one academic clinician in internal medicine, and one academic clinician in nuclear medicine. The panelists were invited for a face-to-face meeting to judge appropriateness of SPECT-MPI and independently assign a specific indication (scenario), whenever possible, for each case in accordance with ACCF/ASNC appropriateness scenarios.
  
  
  RESULTS
  Based on the 2005 ACCF/ASNC criteria, SPECT-MPI studies were judged appropriate for 211 (72.5%), uncertain for 36 (12.4%), inappropriate for 32 (11.0%), and unclassifiable for 12 (4.1%) referrals. The same figures based on the 2009 version were 219 (75.3%), 15 (5.2%), 49 (16.8%), and 8 (2.7%) patients, respectively. Overall agreement between the 2005 and 2009 versions was good (κ 0.63). Lack of chest pain and age below 60 years were significant indicators increasing the likelihood of inappropriate referrals by 2.9-3.4 fold. Absence of diabetes mellitus and hypertension, a normal lipid profile, lack of a past history of myocardial infarction or cardiovascular interventions (CABGs or PCI), as well as lack of application and exercise ECG stress test as the gate keeper (keeping abnormal ETT or inability of the patient to perform exercise as the appropriate indication for SPECT-MPI referral) were significant indicators, decreasing the odds of appropriate referrals. Generally a higher percentage of referrals with inappropriate indications had normal MPI.
  
  
  CONCLUSIONS
  Our study provides an evidence for the fact that SPECT-MPI ordering practices in our developing community largely parallel the ACCF/ASNC recommendations. The implementation of appropriateness criteria is feasible in clinical settings and might provide an alternative to utilization management.
authors.affiliation: Research Institute for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. agholam1@jhmi.edu
authors.forename: Ali
authors.initials: A
authors.lastname: Gholamrezanezhad
authors.forename: Ahmadali
authors.initials: A
authors.lastname: Shirafkan
authors.forename: Sahar
authors.initials: S
authors.lastname: Mirpour
authors.forename: Mehdi
authors.initials: M
authors.lastname: Rayatnavaz
authors.forename: Azita
authors.initials: A
authors.lastname: Alborzi
authors.forename: Mehdi
authors.initials: M
authors.lastname: Mogharrabi
authors.forename: Sepideh
authors.initials: S
authors.lastname: Hassanpour
authors.forename: Mohammadali
authors.initials: M
authors.lastname: Ramezani
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D003906:Developing Countries / Q000706:statistics & numerical data*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006801:Humans; D007492:Iran / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000706:statistics & numerical data*; D015995:Prevalence; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D015899:Tomography, Emission-Computed, Single-Photon / Q000706:statistics & numerical data*