The ACC’s Cardiac Stress Testing Appropriate Use Criteria Answer the Wrong Question

Dr. William Follansbee is the chairman of the American College of Cardiology/American Society of Nuclear Cardiology (ACC/ASNC) task force on non-invasive cardiac imaging and the director of nuclear cardiology at the University of Pittsburgh Medical Center Cardiovascular Institute.He recently published an editorial in the Pittsburgh Post Gazette in which he criticized the local Blue Cross/Blue Shield carrier, Highmark, for restricting the use of nuclear cardiac stress testing in favor of sonographic cardiac stress testing (a.k.a. stress echocardiography). Dr. Follansbee made several arguments as to why he believed that Highmark’s restriction of nuclear cardiac stress testing was wrong.

One of his core arguments is that “patients will be…denied access to appropriately indicated nuclear cardiology tests ordered by their physicians” (emphasis is mine). He (indirectly) references the ACC’s 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging in support of this argument. This document identifies clinical scenarios where a group of experts reached consensus that nuclear cardiac stress testing was appropriate. Dr. Follansbee fails to mention that the ACC also publishes an analogous document called 2008 Appropriateness Criteria for Stress Echocardiography, which uses the same methodology to identify clinical scenarios where a group of experts reached consensus that sonographic cardiac stress testing was appropriate and which illustrates that indications and test performance characteristics for nuclear and echocardiographic stress testing are virtually the same. That said, neither of these ACC documents explicitly identifies where nuclear cardiac stress testing is preferable to sonographic cardiac stress testing and vice versa.

Appropriateness criteria give a semblance of objectivity as to when cardiac stress testing is indicated, but since there are many situations in which the ACC suggests that both nuclear and echocardiographic stress testing are indicated, they give no explicit guidance on which modality is preferred in a situation in which when they are both indicated. The question that doctors like me actually need answered is two-fold: For a given clinical situation 1) is a cardiac stress test indicated and 2) should I order a nuclear or echocardiographic stress test? Since the ACC cardiac stress testing appropriateness criteria guidelines did not address which testing modality is preferred where they are both indicated, Highmark did. Although Highmark’s answer apparently did not meet Dr. Follansbee’s approval, their preference of sonographic over nuclear cardiac stress testing actually makes a lot of sense.

All other things being equal, a safer test is preferable to a riskier test, and a less expensive test is preferable to a more expensive test. Guess what? With respect to “all other things”, nuclear and sonographic cardiac stress testing are essentially equal; even the ACC’s appropriateness criteria say so: “The overwhelming majority of final ratings of cardiac RNI [i.e., nuclear stress testing] and stress echocardiography [i.e., sonographic stress testing] were concordant for similar clinical indications.” Nuclear and sonographic cardiac stress testing have nearly identical sensitivities and specificities; if anything, the specificity of sonographic cardiac stress testing even seems to be somewhat better. Guess what else? Sonographic cardiac stress testing is safer than nuclear cardiac stress testing because it does not use carcinogenic ionizing radiation, and sonographic cardiac stress testing is significantly less expensive than nuclear cardiac stress testing. As such, Highmark’s preference of sonographic cardiac stress testing over nuclear cardiac stress testing is appropriate.

It’s no longer news that America’s health care costs are high and rising with no improvement in our mediocre quality. Through its justified preference of sonographic to nuclear cardiac stress testing, Highmark has identified a way to safely improve (or at worst not decrease) quality and simultaneously decrease cost. This is win-win and a powerful example of comparative effectiveness research, although not referre  d to as such. I do not know whose interests Dr. Follansbee primarily had at heart in arguing for less safe, more expensive, and no more accurate nuclear cardiac stress testing over sonographic cardiac stress testing, but it seems to me that it was neither individual patients nor society at large. Regardless, the ACC should issue a guideline that explicitly states when sonographic cardiac stress testing is preferred to nuclear and vice versa. Sure, this would likely anger many cardiologists and nuclear medicine physicians who make a nice living performing nuclear stress testing, but we should practice medicine with our patients’ best interests primarily at heart, not our own.

Adam Rothschild, MD, MA, is a practicing, board-certified family physician with Handelsman Family Practice, a 3-physician practice near Pittsburgh, PA, where he is in charge of his practice’s electronic health record system. Adam received his BS from Tufts University and his MD from the University of Illinois. He is an adjunct assistant professor of Biomedical Informatics at the University of Pittsburgh School of Medicine. He is founder of the blog, Doctrelo, where this piece first appeared.

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