Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria
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.
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.
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%).
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.
KeywordsCAD Exercise testing Multimodality Others
Appropriate use criteria
Coronary artery bypass grafting
Coronary artery disease
Clinical decision support mechanism
Computed tomography angiography
Electronic health record
Exercise treadmill testing
Myocardial perfusion imaging
Protecting Access to Medicare Act
Percutaneous coronary intervention
Positron emission tomography
Single-photon emission computed tomography
Dr. Spalding and Dr. Xu are employees of Astellas Pharma Global Development, Inc. They provided critical review of the manuscript, but were not involved in data analysis. Dr. Dorbala is a member of an advisory board for General Electric Health Care. Dr. Di Carli has received consulting fees from Sanofi and General Electric. Dr. Blankstein receives research funding from Amgen, Inc. and Astellas Pharma Global Development, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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