March 27th, 2014

What’s Behind the Decline in Nuclear MPI Use?


A new JAMA study shows a sharp decline since 2006 in the use of nuclear myocardial perfusion imaging (MPI).  Edward McNulty and colleagues examined trends in MPI use within a large, community-based population. MPI was used for 302,506 patients at 19 facilities. From 2000 until 2006, MPI use increased by a relative 41%. However, between 2006 and 2011, it declined a relative 51%. Declines were greater for outpatients than for inpatients (58% vs. 31%) and for those younger than 65. This decrease could not be explained by an increase in other imaging methods. 

CardioExchange’s John Ryan asked Kim Williams, Vice President of ACC and Chief of Cardiology at Rush University School of Medicine, to give us his perspective on this decline in MPI use, particularly whether he’s surprised by the decline, if it’s reflected outside of the study population, and what it means for patients.

These data from the JAMA study may indeed be representative, with some busy centers claiming to have had a 40% drop in nuclear volume.  This decrease was primarily due to

1) Appropriate Use Criteria being published and then publicized in 2005, leading to a marked decrease in testing of asymptomatic individuals, low-risk patients, and annual or semi-annual follow-up studies in asymptomatic individuals with coronary artery disease, often post-CABG or PCI;

2) Radiology Benefit Managers putting up barriers to imaging, not necessarily based on our appropriate use criteria; and

3) the Deficit Reduction Act of 2005, which reduced the technical component of imaging tests to that of the hospital outpatient prospective payment system (HOPPS), despite American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) surveys at that time indicating that payment should be higher in the Medicare Fee Schedule.

This latter issue was compounded in 2010 by a flawed RUC survey, which led to a further marked reduction in the technical component (with no 4-year phase-in, as was given to stress echocardiography), making it less feasible to practice outpatient nuclear imaging; and sending patients to other practitioners rather than one’s own lab brought up issues of liability and trust, reducing shift of the site of service to some hospitals.

It would be important to compare this decline in MPI use with stress echo volume over the same period;  I suspect the downturn was not as dramatic, as some practitioners moved from “nuclear only” to using stress echo with greater frequency.

5 Responses to “What’s Behind the Decline in Nuclear MPI Use?”

  1. Good summary.

    I hope cardiologists have the courage to look back and learn from this story.

    I agree strongly with Dr. Williams.

    You notice that not one of the cited reasons for the decline was clinical.

    And that is why it will take courage to really see what was happening.

    The word stewardship comes to mind.

  2. Enrique Guadiana, Cardiology says:

    I always wonder why a physician has to send their patients to other practitioners rather than one’s own lab to avoid issues of liability and trust, but this rule doesn’t apply to hospital physicians. Why they don’t send their patients to other hospital to avoid this issues. This implies physicians are not trust worldly but hospitals are.

    I think is important to review a previous post about a growing problem of radiation in cardiology and a commentary from Dr Eugenio Picano “Even in the best centers, and even when the income of doctors is not related to number of examinations performed, 30 to 50% of examinations are totally or partially inappropriate according to specialty recommendations,”

  3. Jean-Pierre Usdin, MD says:

    Thank you for these informations
    According to JAMA paper, the decline in MPI was noticed before awareness program published recently in European Heart Journal about the Xrays exposure due to cardiologists’ prescritions!
    Probably the increasing fiability and facility of stress echocardiogram explain a part of MPI decline. Of course purists will tell me: “The informations on a scientific basis are not exactly the same”.
    But in day-life practice I see at least three important benefits:

    safety (except for the exercise but..)
    immediate results
    pictures that speak to physician and his patient.
    Thank you for your nice discussion

  4. Stewart Mann, DM (Oxon), FRCP(UK), FRACP says:

    The reasons suggested are all related to funding issues in the USA. Although I don’t have figures to hand, from knowledge of personal and local practice I would guess that there has been a significant decline outside the USA too. As suggested, this may largely be due to clinical preference inclusing the increasing applicability and reliability of stress echo. Usage of nuclear studies locally (New Zealand) was of course never in the same league as that in the US.

  5. Regina Druz, MD says:

    It is Interesting that the decline in MPI occurred with no specific or structured AUC program in place. Studies form Mayo clinic, and other centers documented that education on use of AUC does not necessarily result in a decrease of inappropriate studies. It may be that the Kaiser model of reimbursement of care, which is not linked to number of procedures is playing more of a role: as far as I know, they do jot use RBMs for pre certification. It is also notable that the prevalence of MI had dropped 27% in the study period. A study by Rozanski et al in JACC a couple of years ago documented a decrease in abnormal SPECT MPI findings, and that corresponds to the same time period as reported by the authors. It is possible,that the drop in SPECT volume is reflective of the changing prevalence of obstructive CAD.