Abstract 13507: Inappropriate Preoperative Stress Testing is Common Across Medical Specialties: A Single-Center Review
Introduction: According to appropriate use criteria, preoperative stress testing in asymptomatic patients is considered “rarely appropriate” in patients with: 1) moderate to good functional capacity (≥4 METs), 2) no clinical risk factors, or who are 3) asymptomatic following revascularization, normal stress test, or normal coronary angiography within one year. Stress testing is also not recommended in patients estimated to be low-risk (<1%) for adverse cardiac events according to ACC/AHA guidelines.
Hypothesis: We hypothesized that cardiologists, when compared with other specialties, would be less likely to order preoperative testing in low-risk patients or for rarely appropriate indications.
Methods: We reviewed preoperative stress tests for non-cardiac surgery performed at Hershey Medical Center from January 2012 through December 2014. Stress tests performed for solid organ transplant evaluation were excluded. Chi square analysis was used to compare frequencies of test appropriateness and patient risk. Risk for adverse cardiac events was estimated using the National Surgical Quality Improvement Program (NSQIP) Myocardial Infarction and Cardiac Arrest (NSQIP MICA) risk calculator.
Results: 505 preoperative stress tests meeting study criteria were analyzed. Out of 219 preoperative stress tests ordered by cardiologists, 121 (55%) were classified as “rarely appropriate”, compared with 217 of 286 stress tests (76%) ordered by other specialties (p<0.0001). Median cardiac risk for 361 patients with sufficient data to estimate by NSQIP MICA was 0.6% (interquartile range 0.4-1.2%). 248 of 361 stress tests (69%) were performed on patients estimated to be low-risk. Frequency of low-risk testing did not significantly differ (p=0.32) between cardiologists (96 of 146, 66%) and other specialties (152 of 215, 71%).
Conclusions: Cardiologists were significantly less likely to order rarely appropriate stress tests compared with other specialties. The majority of stress tests ordered by cardiologists and by other specialties, however, were rarely appropriate and in patients at low-risk (<1%) for cardiac complications. Interventions to reduce inappropriate preoperative stress testing, therefore, require a multispecialty approach.
Author Disclosures: B. Peterson: None. M. Ghahramani: None. M. Emerich: None. B. Pinto: None. M. Devine: None. A. Foy: None.
- © 2016 by American Heart Association, Inc.