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Physician Decision Making and Trends in the Use of Cardiac Stress Testing in the United States: An Analysis of Repeated Cross-sectional DataPhysician Decision Making and Trends in the Use of Cardiac Stress Testing

Joseph A. Ladapo, MD, PhD; Saul Blecker, MD, MHS; and Pamela S. Douglas, MD
[+] Article, Author, and Disclosure Information

From New York University School of Medicine, New York, New York, and Duke University School of Medicine, Durham, North Carolina.

Note: Dr. Ladapo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Grant Support: By a K23 Career Development Award from the National Heart, Lung, and Blood Institute (grant 1 K23 HL116787-01A1; Dr. Ladapo) and by the National Center for Advancing Translational Sciences (grant KL2 TR000053; Dr. Blecker).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0296.

Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Ladapo (e-mail, joseph.ladapo@nyumc.org) with written use agreement. Data set: Freely available at www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.

Requests for Single Reprints: Joseph A. Ladapo, MD, PhD, New York University School of Medicine, Department of Population Health, 550 First Avenue, VZ30 6th Floor, Room 614, New York, NY 10016.

Current Author Addresses: Dr. Ladapo: New York University School of Medicine, Department of Population Health, 550 First Avenue, VZ30 6th Floor, Room 614, New York, NY 10016.

Dr. Blecker: New York University School of Medicine, Department of Population Health, 550 First Avenue, VZ30 6th Floor, Room 648, New York, NY 10016.

Dr. Douglas: Duke University School of Medicine, 7022 North Pavilion, Durham, NC 27715.

Author Contributions: Conception and design: J.A. Ladapo, P.S. Douglas.

Analysis and interpretation of the data: J.A. Ladapo, P.S. Douglas.

Drafting of the article: J.A. Ladapo.

Critical revision of the article for important intellectual content: J.A. Ladapo, S. Blecker, P.S. Douglas.

Final approval of the article: J.A. Ladapo, S. Blecker, P.S. Douglas.

Statistical expertise: J.A. Ladapo.

Obtaining of funding: J.A. Ladapo.

Collection and assembly of data: J.A. Ladapo.


Ann Intern Med. 2014;161(7):482-490. doi:10.7326/M14-0296
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Background: Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure.

Objective: To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making.

Design: Analyses of repeated cross-sectional data.

Setting: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010).

Patients: Adults without coronary heart disease.

Measurements: Cardiac stress test referrals and inappropriate use.

Results: Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10 000 visits to 45 per 10 000 visits. No trend was found toward more frequent testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).

Limitation: Cross-sectional design with limited clinical data.

Conclusion: National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease.

Primary Funding Source: National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.

Figures

Grahic Jump Location
Figure 1.

Number of cardiac stress tests ordered or performed for adults without coronary heart disease in U.S. ambulatory care visits, 1993–2010.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Cardiac stress tests ordered or performed for adults in U.S. ambulatory care visits, by race/ethnicity, 1993–2010.

Error bars represent 95% CIs. Top. Rate of tests ordered or performed for adults without coronary heart disease. Bottom. Percentage of tests ordered or performed with imaging.

Grahic Jump Location

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Summary for Patients

Trends in the Use of Stress Testing to Diagnose Coronary Heart Disease

The full report is titled “Physician Decision Making and Trends in the Use of Cardiac Stress Testing in the United States. An Analysis of Repeated Cross-sectional Data.” It is in the 7 October 2014 issue of Annals of Internal Medicine (volume 161, pages 482-490). The authors are J.A. Ladapo, S. Blecker, and P.S. Douglas.

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