Study to Evaluate Current Trends in Appropriate Usage of Tread Mill Exercise Testing

Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria

BACKGROUND

An upcoming national mandate will require consultation of appropriate use criteria (AUC) through a clinical decision support mechanism (CDSM) for advanced imaging. We aimed to evaluate our current ability to ascertain test appropriateness.

METHODS

We prospectively collected data on 288 consecutive stress tests and coronary computed tomography angiography studies for medical inpatients. Study appropriateness was determined independently by two physicians using the 2013 Multimodality AUC.

RESULTS

The median age of the study population was 66 years [interquartile range (IQR) 56, 75], 40.8% were female, and 52.8% had a history of coronary artery disease. Review of the electronic health record (EHR) alone was sufficient to deem appropriateness for 87.2% of cases. The most common reason it was insufficient was inability to determine if the patient could exercise (59.5%). After reviewing the EHR and pilot CDSM data together, appropriateness could be determined for 95.8% of the cases. The most common reason appropriateness could not be determined was that the exam indication was not addressed by an AUC criterion (83.3%).

CONCLUSION

In preparing for the mandate, it will be important for future CDSM to obtain information on the patient's ability to exercise and for future AUC to include additional indications that are not currently addressed.

Adherence to American Heart Association and American College of Cardiology guidelines for exercise tolerance test in cardiovascular clinics

Introduction: Considering the increased expenditure in public health sector, especially the increased cost in hospitals and clinics, there is an urgent need to control these costs mainly by ensuring adherence to clinical guidelines for diagnostic procedures. In this study we aim to investigate the adherence of heart clinics to guideline for exercise tolerance test.

Methods: This cross-sectional study was performed on 308 patients who were referred for ECG exercise test in 3 clinics located in the city of Shiraz, Iran in 2018. Demographic and clinical data were recorded and the indications of exercise test for each patient was reviewed according to the ACC/AHA guideline for exercise tolerance test.

Results: Exercise tests were found to be inappropriately done in 121 (39.3%) participants. Among the patients for whom the test was done without indication 79 (65.3%) were women and the gender difference was statistically significant (P < 0.01); women were 18.5% more likely to undergo exercise test without indication. There was more inappropriate tests among nonanginal pain subsets comparing to other presenting symptoms (P < 0.001). Age, coronary risk factors, reason for performing exercise tests and private health system were not predictors of inappropriate use (P > 0.05).

Conclusion: This study confirms that more than one third of exercise tests done in the participants are inappropriate. Wide availability of exercise test makes it vulnerable to overuse and additional unnecessary cost to health care systems.