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Inappropriate use of cardiac stress tests with imaging linked to excess costs, harm
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Inappropriate cardiac stress tests with imaging may cost approximately $500 million and lead to 491 future cases of cancer per year, according to a new analysis.
Researchers also found no evidence that black patients have a lower likelihood of receiving a cardiac stress test compared with white patients, but they found some evidence that Hispanic patients might be less likely to receive a cardiac stress test.
Using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2010, Joseph A. Ladapo, MD, PhD, and colleagues analyzed visits to office-based physicians and hospital outpatient clinics by patients aged at least 18 years without a diagnosis of CHD. The primary outcome was performance of or referral to cardiac stress testing.
Joseph A. Ladapo
They assessed whether cardiac stress testing was associated with patient or provider characteristics; whether an order for cardiac stress testing was appropriate or inappropriate based on criteria from the American College of Cardiology, American Society of Nuclear Cardiology and American Society of Echocardiography; whether usage varied by race and ethnicity; and the potential health and economic impact of inappropriate testing in the United States.
More cardiac stress tests ordered
Ambulatory visits in which a cardiac stress test was ordered or performed rose from 28 per 10,000 visits in 1993-1995 to 45 per 10,000 visits in 2008-2010. The trend was significant in unadjusted analyses (P<.01), but not after adjustment for patient characteristics, clinical risk factors and provider characteristics (P=.134).
Among cardiac stress tests ordered, the percentage of tests with imaging rose from 59% in 1993-1995 to 87% in 2008-2010. This change remained significant after adjustment for patient characteristics, clinical risk factors and provider characteristics (P<.001).
When the researchers assessed appropriateness, they found that 30% of cardiac stress tests with imaging and 14% of tests without imaging were rarely appropriate. The most common diagnosis after inappropriate use was hypertension.
Evidence of harm
The annual costs of the inappropriate tests were $501 million ($494 million for tests with imaging), according to the researchers’ estimates. Further, patients were exposed to up to 10.2 million mSv of unnecessary radiation annually from inappropriate testing, a figure corresponding to 491 patients per year developing cancer later in life.
“While this number might seem relatively small, we must remember that ‘first, do no harm’ is one of the guiding principles of medicine,” Ladapo, assistant professor of medicine and population health at NYU Langone Medical Center, said in a press release.
The researchers found no evidence that black patients were less likely to receive a cardiac stress test compared with white patients (OR=0.91; 95% CI, 0.69-1.21). They did, however, observe a trend toward Hispanic patients being less likely to receive a cardiac stress test (OR=0.75; 95% CI, 0.55-1.02).
“Cardiac stress testing is an important clinical tool, but we are overusing imaging for reasons unrelated to clinical need,” Ladapo said in the release. “This is causing preventable harm and increasing health care costs. More efforts, such as clinical decision support, are needed to reduce unnecessary stress testing.”
Disclosure: The study was funded by the NHLBI and the National Center for Advancing Translational Sciences. Ladapo reports consulting for CardioDx Inc., but did not receive compensation from the firm for the study.
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