Advertisement

Implementation of a Computerized Order Entry Tool to Reduce the Inappropriate and Unnecessary Use of Cardiac Stress Tests With Imaging in Hospitalized Patients

      The rising use of imaging cardiac stress tests has led to potentially unnecessary testing. Interventions designed to reduce inappropriate stress testing have focused on the ambulatory setting. We developed a computerized order entry tool intended to reduce the use of imaging cardiac stress tests and improve appropriate use in hospitalized patients. The tool was evaluated using preimplementation and postimplementation cohorts at a single urban academic teaching hospital. All hospitalized patients referred for testing were included. The co-primary outcomes were the use of imaging stress tests as a percentage of all stress tests and the percentage of inappropriate tests, compared between the 2 cohorts. There were 478 patients in the precohort and 463 in the postcohort. The indication was chest pain in 66% and preoperative in 18% and was not significantly different between groups. The use of nonimaging stress tests increased from 4% in the pregroup to 15% in the postgroup (p <0.001). Among very low–risk chest pain patients, the use of nonimaging stress tests increased from 7% to 25% (p <0.001). Inappropriate testing did not change significantly between groups (12% vs 11%). Inappropriate tests were most often preoperative evaluations (83%). In conclusion, our computerized ordering tool significantly increased the use of nonimaging cardiac stress tests and reduced the use of imaging tests yet was not able to reduce inappropriate use. Our study highlights the differences in cardiac stress testing between hospitalized and ambulatory patients.
      To read this article in full you will need to make a payment

      References

        • Lucas F.L.
        • DeLorenzo M.A.
        • Siewers A.E.
        • Wennberg D.E.
        Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001.
        Circulation. 2006; 113: 374-379
        • Ladapo J.A.
        • Blecker S.
        • Douglas P.S.
        Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.
        Ann Intern Med. 2014; 161: 482-490
        • Hendel R.C.
        • Berman D.S.
        • Di Carli M.F.
        • Heidenreich P.A.
        • Henkin R.E.
        • Pellikka P.A.
        • Pohost G.M.
        • Williams K.A.
        ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology appropriate use criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society for Cardiac Computed Tomography, the Society for Cardiac Magnetic Resonance, and the Society of Nuclear Medicine.
        J Am Coll Cardiol. 2009; 53: 2201-2229
        • Douglas P.S.
        • Garcia M.J.
        • Haines D.E.
        • Lai W.W.
        • Manning W.J.
        • Patel A.R.
        • Picard M.H.
        • Polk D.M.
        • Ragosta M.
        • Ward R.P.
        • Weiner R.B.
        ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation appropriate use criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance.
        J Am Soc Echocardiogr. 2011; 24: 229-267
        • Hendel R.C.
        • Cerqueira M.
        • Douglas P.S.
        • Caruth K.C.
        • Allen J.M.
        • Jensen N.C.
        • Pan W.
        • Brindis R.
        • Wolk M.
        A multicenter assessment of the use of single-photon emission computed tomography myocardial perfusion imaging with appropriateness criteria.
        J Am Coll Cardiol. 2010; 55: 156-162
        • Gibbons R.J.
        • Askew J.W.
        • Hodge D.
        • Kaping B.
        • Carryer D.J.
        • Miller T.
        Appropriate use criteria for stress single-photon emission computed tomography sestamibi studies: a quality improvement project.
        Circulation. 2011; 123: 499-503
        • Lin F.Y.
        • Dunning A.M.
        • Narula J.
        • Shaw L.J.
        • Gransar H.
        • Berman D.S.
        • Min J.K.
        Impact of automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study.
        J Am Coll Cardiol. 2013; 62: 308-316
        • Gertz Z.M.
        • O'Donnell W.
        • Raina A.
        • Litwack A.J.
        • Balderston J.R.
        • Goldberg L.R.
        Application of appropriate use criteria in the hospital setting: limitations of the criteria and areas for improved practice.
        Clin Cardiol. 2015; 38: 8-12
        • Gibbons R.J.
        • Balady G.J.
        • Bricker J.T.
        • Chaitman B.R.
        • Fletcher G.F.
        • Froelicher V.F.
        • Mark D.B.
        • McCallister B.D.
        • Mooss A.N.
        • O'Reilly M.G.
        • Winters W.L.
        ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (committee on exercise testing).
        J Am Coll Cardiol. 2002; 40: 1531-1540
        • Wolk M.J.
        • Bailey S.R.
        • Doherty J.U.
        • Douglas P.S.
        • Hendel R.C.
        • Kramer C.M.
        • Min J.K.
        • Patel M.R.
        • Rosenbaum L.
        • Shaw L.J.
        • Stainback R.F.
        • Allen J.M.
        ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation appropriate use criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2014; 63: 380-406
        • Than M.
        • Cullen L.
        • Reid C.M.
        • Lim S.H.
        • Aldous S.
        • Ardagh M.W.
        • Peacock W.F.
        • Parsonage W.A.
        • Ho H.F.
        • Ko H.F.
        • Kasliwal R.R.
        • Bansal M.
        • Soerianata S.
        • Hu D.
        • Ding R.
        • Hua Q.
        • Seok-Min K.
        • Sritara P.
        • Sae-Lee R.
        • Chiu T.F.
        • Tsai K.C.
        • Chu F.Y.
        • Chen W.K.
        • Chang W.H.
        • Flaws D.F.
        • George P.M.
        • Richards A.M.
        A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study.
        Lancet. 2011; 377: 1077-1084
        • Than M.
        • Aldous S.
        • Lord S.J.
        • Goodacre S.
        • Frampton C.M.A.
        • Troughton R.
        • George P.
        • Florkowski C.M.
        • Ardagh M.
        • Smyth D.
        • Jardine D.L.
        • Peacock W.F.
        • Young J.
        • Hamilton G.
        • Deely J.M.
        • Cullen L.
        • Richards A.M.
        A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial.
        JAMA Intern Med. 2014; 174: 51-58
        • Gomez M.A.
        • Anderson J.L.
        • Karagounis L.A.
        • Muhlstein J.B.
        • Mooers F.B.
        An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO).
        J Am Coll Cardiol. 1996; 28: 25-33
        • Vanzetto G.
        • Ormezzano O.
        • Fagret D.
        • Comet M.
        • Denis B.
        • Machecourt J.
        Long-term additive prognostic value of thallium-201 myocardial perfusion imaging over clinical and exercise stress test in low to intermediate risk patients: study in 1137 patients with 6-year follow-up.
        Circulation. 1999; 100: 1521-1527
        • Jeetley P.
        • Burden L.
        • Stoykova B.
        • Senior R.
        Clinical and economic impact of stress echocardiography compared with exercise electrocardiography in patients with suspected acute coronary syndrome but negative troponin: a prospective randomized controlled trial.
        Eur Heart J. 2007; 28: 204-211
        • Safavi K.C.
        • Li S.X.
        • Dharmarajan K.
        • Venkatesh A.K.
        • Strait K.M.
        • Lin H.
        • Lowe T.J.
        • Fazel R.
        • Nallamothu B.K.
        • Krumholz H.M.
        Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes.
        JAMA Intern Med. 2014; 174: 546-553