Abstract 15561: Physician Decision-Making and Trends in Use of Cardiac Stress Testing to Diagnose Coronary Heart Disease in The United States
Introduction: Utilization of cardiac stress testing for CHD has come under intense scrutiny because of concerns about explosive growth, high costs, and patient safety related to radiation exposure.
Hypothesis: Changing population demographics and risk factors do not explain recent growth in stress testing.
Method: We analyzed a nationally representative US sample of 839,354 adult ambulatory visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2010. Patients with CHD were excluded. The main outcome was survey-weighted incidence of referrals for or performance of stress testing. Multivariable logistic regression was used to test time trends, with year modeled as a linear predictor, and we included clinical risk factors (smoking, diabetes, dyslipidemia, and hypertension), whether the patient’s reason for visiting the physician was chest pain, physician specialty, sociodemographic characteristics, geographic location, and insurance status.
Result: The annual number of adult ambulatory visits that resulted in a cardiac stress test being ordered or performed increased from 1.86 million in 1993-1997 (31 in 10,000 visits) to 3.89 million in 2006-2010 (46 in 10,000 visits). After adjusting for clinical and sociodemographic characteristics, there was no evidence of a time trend in stress testing use (P=0.48 for trend). However, the portion of cardiac stress tests performed with imaging increased from 64% (95% CI 48%-79%) in 1993-1997 to 87% (95% CI 79%-96%) in 2006-2010 (P<0.001 for trend after adjustment).
Conclusion: Growth in physician use of stress testing may be attributable to changes in population demographics, but rising substitution of imaging for nonimaging tests makes tracking of stress imaging alone a misleading metric for utilization. Nonetheless, our findings support and further refine concerns voiced by professional societies and insurers about stress test utilization.
- © 2013 by American Heart Association, Inc.