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.