Can physicians identify inappropriate nuclear stress tests? An examination of inter-rater reliability for the 2009 appropriate use criteria for radionuclide imaging

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.

Discrepancy between patient-reported and clinician-documented symptoms for myocardial perfusion imaging: initial findings from a prospective registry

BACKGROUND

Occasionally, the symptoms reported by patients disagree with those documented in the medical record. We designed the Patient Centered Assessment of Symptoms (PCAS) registry to measure discrepancies between patient-reported and clinician-documented symptoms.

OBJECTIVE

Use patient-derived symptoms data to measure discrepancies with clinical documentation.

METHODS

The PCAS registry captured data from a prospective cohort of patients undergoing myocardial perfusion imaging (MPI) and includes free response and structured questions to gauge symptoms. Clinician-documented symptoms were extracted from the patients' medical records. The appropriateness of testing was determined twice: once using the patient-reported symptoms and once using the clinician-documented symptoms.

RESULTS

A total of 90 subjects were enrolled, among whom diabetes (36.7%), prior coronary disease (28.9%), hypertension (80.0%) and hyperlipidemia (85.6%) were common. Percentage of patient-reported symptoms compared to clinician-documented symptoms and agreement were as follows: chest pain (patient 29.0%, clinician 36.6%, moderate [kappa = 0.54]), chest pressure (patient 18.3%, clinician 10.8%, fair [kappa = 0.27]), dyspnea (patient 41.0%, clinician 36.6%, fair [kappa = 0.28]), onset with exertion (patient 61.7%, clinician 59.6%, slight [kappa = 0.17]), symptoms same as prior coronary artery disease (patient 46.2%, clinician 15.3%, slight [kappa = 0.01]). As a result of these inconsistencies, appropriateness ratings were different for 13.3% (n = 12) subjects.

CONCLUSION

In this prospective registry of patients undergoing MPI, we observed substantial disagreements between patient-reported and clinician-documented symptoms. Disagreement resulted in a considerable proportion of MPI appropriateness ratings also being incongruous.

Appropriately testing patients with intermediate risk for coronary artery disease: how well are we doing?

BACKGROUND

Cardiovascular risk assessment and stratification of stable coronary artery disease represents a pivotal component of coronary artery disease management. The introduction of risk stratification tools has advanced the detection of patients with intermediate to high risk for coronary artery events. These patients will ultimately undergo non-invasive and invasive cardiovascular testing.

OBJECTIVE

To synthesise evidence illustrating risk stratification tools and non-invasive testing for patients with intermediate risk for coronary artery disease and suggest a simple method for clinicians to follow prior to ordering non-invasive cardiovascular testing.

STUDY SELECTION

Literature review of PubMed and MEDLINE Central on studies and evidence highlighting the appropriate use criteria for radionuclide myocardial perfusion imaging.

FINDINGS AND CONCLUSIONS

Overtestingusing myocardial perfusion imaging is well documented in several studies in the literature. Few studies highlighted the importance of the appropriate use criteria for radionuclide myocardial perfusion imaging, which can reduce unnecessary testing in patients with suspected coronary artery disease. Herein, we propose 'Simple Steps to Follow' to be considered by clinicians prior to ordering radionuclide myocardial perfusion imaging. The target audience of this article is internal and family medicine primary care physicians and other non-cardiologist physicians.

Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis

BACKGROUND

The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes.

METHODS

We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method.

RESULTS

A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10).

CONCLUSION

Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.