Inter-reader variability of SPECT MPI readings in low- and middle-income countries: Results from the IAEA-MPI Audit Project (I-MAP)

Background Consistency of results between different readers is an important issue in medical imaging, as it affects portability of results between institutions and may affect patient care. The International Atomic Energy Agency (IAEA) in pursuing its mission of fostering peaceful applications of nuclear technologies has supported several training activities in the field of nuclear cardiology (NC) and SPECT myocardial perfusion imaging (MPI) in particular. The aim of this study was to verify the outcome of those activities through an international clinical audit on MPI where participants were requested to report on studies distributed from a core lab. Methods The study was run in two phases: in phase 1, SPECT MPI studies were distributed as raw data and full processing was requested as per local practice. In phase 2, images from studies pre-processed at the core lab were distributed. Data to be reported included summed stress score (SSS); summed rest score (SRS); summed difference score (SDS); left ventricular (LV) ejection fraction (EF) and end- diastolic volume (EDV). Qualitative appraisals included the assessment of perfusion and presence of ischemia, scar or mixed patterns, presence of transient ischemic dilation (TID), and risk for cardiac events (CE). Twenty-four previous trainees from low- and middle-income countries participated (core participants group) and their results were assessed for inter-observer variability in each of the two phases, and for changes between phases. The same evaluations were performed for a group of eleven international experts (experts group). Results were also compared between the groups. Results Expert readers showed an excellent level of agreement for all parameters in both phase 1 and 2. For core participants, the concordance of all parameters in phase 1 was rated as good to excellent. Two parameters which were re-evaluated in phase 2, namely SSS and SRS, showed an increased level of concordance, up to excellent in both cases. Reporting of categorical variables by expert readers remained almost unchanged between the two phases, while core participants showed an increase in phase 2. Finally, pooled LVEF values did not show a significant difference between core participants and experts. However, significant differences were found between LVEF values obtained using different software packages for cardiac analysis. Conclusions In this study, inter-observer agreement was moderate-to-good for core group readers and good-to-excellent for expert readers. The quality of reporting is affected by the quality of processing. These results confirm the important role of the IAEA training activities in improving imaging in low- and middle-income countries.