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Electrocardiogram screening common in low-risk patients, offers little benefit

Despite recommendations to the contrary, low-risk patients undergoing an annual health examination at a primary care practice frequently received an electrocardiogram and thus had a significantly greater likelihood for subsequent cardiac testing and consultations with little potential benefit, according to a study published in JAMA Internal Medicine.

“In 2012, the [U.S. Preventive Services Task Force] recommended against routine [electrocardiograms (ECG)] screening in low-risk patients because there is inadequate evidence for the added utility of ECG in the diagnosis of coronary disease,” R. Sacha Bhatia, MD, MBA, from the Institute for Health Systems Solutions and Virtual Care in Toronto, and colleagues wrote.

However, there is little known about the frequency and impact of such ECGs, they added.

Bhatia and colleagues performed a population-based retrospective cohort study to evaluate how often ECGs are recommended by PCPs after an annual health exam among patients aged 18 years or older with no known cardiac conditions or risk factors. They also evaluated predictive factors of receiving an ECG and the impact of the procedure on downstream cardiac testing. They identified 3,629,859 low-risk primary care patients who had at least one annual health exam between 2010-2011 and 2014-2015 via administrative health care databases from Ontario, Canada.

Data showed that 21.5% of all participants received an ECG within 30 days following an annual health exam. There was significant variation in the proportion of patients receiving ECG testing after an annual health exam among primary care practices (n = 679) and PCPs (n = 8,036), ranging from 1.8% to 76.1% among practices (coefficient of quartile dispersion [CQD] = 0.5), and 1.1% to 94.9% among PCPs (CQD = 0.54). Patients who received an ECG were more than five times more likely to receive additional cardiac tests, visits, procedures or consultations with a specialist compared with those who did not (OR = 5.14; 95% CI, 5.07-5.21; P < .001). In both the ECG and non-ECG groups, there were low rates of death (0.19% vs. 0.16%), cardiac-related hospitalizations (0.46% vs. 0.12%) and coronary revascularizations (0.2% vs. 0.04%).

“The results of this study have considerable health care policy implications,” Bhatia and colleagues concluded. “First, when selecting overuse metrics for quality improvement initiatives, consideration should be given to the impact on downstream testing and outcomes... Our findings suggest that even low-cost procedures, like ECGs in low-risk patients, occur with considerable frequency, and importantly can lead to more advanced testing that adds costs with little potential benefit to patients. Second, measurement of low value care should also attempt to quantify the impact on health outcomes for patients. Finally, quality improvement interventions to reduce low-value care could be designed to more effectively target practices and physicians with high ordering rates to reduce the prevalence of low-value cardiac testing, and the unexplained ordering variation.” – by Alaina Tedesco

Disclosure: The researchers report funding from the Institute for Clinical Evaluative Sciences.