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The risks of inappropriateness in cardiac imaging.

Picano E - Int J Environ Res Public Health (2009)

Bottom Line: Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome.Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war.Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

View Article: PubMed Central - PubMed

Affiliation: Institute of Clinical Physiology, CNR, Pisa, Italy. picano@ifc.cnr.it

ABSTRACT
The immense clinical and scientific benefits of cardiovascular imaging are well-established, but are also true that 30 to 50% of all examinations are partially or totally inappropriate. Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome. Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war. After a long journey across imaging laboratories, he will have stress echo, myocardial perfusion scintigraphy, PET-CT, 64-slice CT, and adenosine-MRI performed, with a cumulative cost of >100 times a simple exercise-electrocardiography test and a cumulative radiation dose of >4,000 chest x-rays, with a cancer risk of 1 in 100. Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

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Related in: MedlinePlus

Future trends in the use of cardiac imaging up to the year 2020. Redrawn from the original data of reference [35].
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f5-ijerph-06-01649: Future trends in the use of cardiac imaging up to the year 2020. Redrawn from the original data of reference [35].

Mentions: The proliferation of cardiac stress imaging may represent an added value when appropriate, and an added cost when inappropriate. Unfortunately, the definition of appropriateness is obvious in theory, but not so straightforward on practical grounds. Unlike prevention and treatment strategies supported by evidence-based practice guidelines, the evidence base for imaging is anecdotal, fragmented, and lacking in prospective clinical trials [9]. As a consequence, the process for developing appropriateness criteria is only partially evidence-based and is heavily weighted by expert consensus [9]. On an arbitrary scale of 1 (most inappropriate) to 9 (most appropriate), indications are classified as “appropriate” (score >7, test is generally acceptable and is a reasonable approach for the indication), “uncertain” (score between 4 and 6, test may be generally acceptable and may be a reasonable approach for the indication), and “inappropriate” (score <3, test is not generally acceptable and is not a reasonable approach for the indication). The most frequent appropriate, uncertain and inappropriate indications met in the clinical practice of high volume laboratories are listed in Table 2. Following these criteria, only 2 out of 3 stress echo (or nuclear stress imaging) tests are appropriate, with similar numbers observed in disparate geographic, cultural and economic situations – from Italy to Australia [5] to the USA [6]. Of interest, the vast majority of inappropriate studies were restricted to only a few patient indications, with the four most frequent inappropriate indications listed in Table 2 account for 88% of all inappropriate examinations [38]. This repetitive pattern of inappropriateness points to a need for quality improvement and educational programs to achieve measurable improvement in results [38]. This is especially important today and in view of the projected spectacular rise of cardiac imaging in the next 15 years [39] (Figure 5).


The risks of inappropriateness in cardiac imaging.

Picano E - Int J Environ Res Public Health (2009)

Future trends in the use of cardiac imaging up to the year 2020. Redrawn from the original data of reference [35].
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC2697934&req=5

f5-ijerph-06-01649: Future trends in the use of cardiac imaging up to the year 2020. Redrawn from the original data of reference [35].
Mentions: The proliferation of cardiac stress imaging may represent an added value when appropriate, and an added cost when inappropriate. Unfortunately, the definition of appropriateness is obvious in theory, but not so straightforward on practical grounds. Unlike prevention and treatment strategies supported by evidence-based practice guidelines, the evidence base for imaging is anecdotal, fragmented, and lacking in prospective clinical trials [9]. As a consequence, the process for developing appropriateness criteria is only partially evidence-based and is heavily weighted by expert consensus [9]. On an arbitrary scale of 1 (most inappropriate) to 9 (most appropriate), indications are classified as “appropriate” (score >7, test is generally acceptable and is a reasonable approach for the indication), “uncertain” (score between 4 and 6, test may be generally acceptable and may be a reasonable approach for the indication), and “inappropriate” (score <3, test is not generally acceptable and is not a reasonable approach for the indication). The most frequent appropriate, uncertain and inappropriate indications met in the clinical practice of high volume laboratories are listed in Table 2. Following these criteria, only 2 out of 3 stress echo (or nuclear stress imaging) tests are appropriate, with similar numbers observed in disparate geographic, cultural and economic situations – from Italy to Australia [5] to the USA [6]. Of interest, the vast majority of inappropriate studies were restricted to only a few patient indications, with the four most frequent inappropriate indications listed in Table 2 account for 88% of all inappropriate examinations [38]. This repetitive pattern of inappropriateness points to a need for quality improvement and educational programs to achieve measurable improvement in results [38]. This is especially important today and in view of the projected spectacular rise of cardiac imaging in the next 15 years [39] (Figure 5).

Bottom Line: Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome.Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war.Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

View Article: PubMed Central - PubMed

Affiliation: Institute of Clinical Physiology, CNR, Pisa, Italy. picano@ifc.cnr.it

ABSTRACT
The immense clinical and scientific benefits of cardiovascular imaging are well-established, but are also true that 30 to 50% of all examinations are partially or totally inappropriate. Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome. Mr. Ulysses, a typical middle-aged "worried-well" asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war. After a long journey across imaging laboratories, he will have stress echo, myocardial perfusion scintigraphy, PET-CT, 64-slice CT, and adenosine-MRI performed, with a cumulative cost of >100 times a simple exercise-electrocardiography test and a cumulative radiation dose of >4,000 chest x-rays, with a cancer risk of 1 in 100. Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.

Show MeSH
Related in: MedlinePlus