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

  • Sanjay Divakaran
  • Avinainder Singh
  • Ersilia M. DeFilippis
  • Timothy W. Churchill
  • Sarah Cuddy
  • Yin Ge
  • Ivan K. Ip
  • Wunan Zhou
  • Hicham Skali
  • Viviany R. Taqueti
  • Sharmila Dorbala
  • James Spalding
  • Yanqing Xu
  • Ramin Khorasani
  • Marcelo F. Di Carli
  • Maria A. Yialamas
  • Ron BlanksteinEmail author
  • for the Brigham and Women’s Hospital Internal Medicine Residency
Original Article

Abstract

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.

Keywords

CAD Exercise testing Multimodality Others 

Abbreviations

AUC

Appropriate use criteria

CABG

Coronary artery bypass grafting

CAD

Coronary artery disease

CDSM

Clinical decision support mechanism

CTA

Computed tomography angiography

ECG

Electrocardiogram

EHR

Electronic health record

ETT

Exercise treadmill testing

MI

Myocardial infarction

MPI

Myocardial perfusion imaging

PAMA

Protecting Access to Medicare Act

PCI

Percutaneous coronary intervention

PET

Positron emission tomography

SPECT

Single-photon emission computed tomography

Notes

Disclosures

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.

Supplementary material

12350_2019_1955_MOESM1_ESM.pptx (1.6 mb)
Electronic supplementary material 1 (PPTX 1647 kb)

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Copyright information

© American Society of Nuclear Cardiology 2019

Authors and Affiliations

  • Sanjay Divakaran
    • 1
    • 2
  • Avinainder Singh
    • 3
  • Ersilia M. DeFilippis
    • 4
  • Timothy W. Churchill
    • 5
  • Sarah Cuddy
    • 1
  • Yin Ge
    • 1
  • Ivan K. Ip
    • 6
  • Wunan Zhou
    • 1
  • Hicham Skali
    • 1
    • 2
  • Viviany R. Taqueti
    • 1
  • Sharmila Dorbala
    • 1
  • James Spalding
    • 6
  • Yanqing Xu
    • 6
  • Ramin Khorasani
    • 7
  • Marcelo F. Di Carli
    • 1
    • 2
  • Maria A. Yialamas
    • 8
  • Ron Blankstein
    • 1
    • 2
    Email author
  • for the Brigham and Women’s Hospital Internal Medicine Residency
  1. 1.Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  2. 2.Cardiovascular Division, Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  3. 3.Department of MedicineYale University School of MedicineNew HavenUSA
  4. 4.Division of Cardiology, Department of MedicineNew York Presbyterian-Columbia University Irving Medical CenterNew YorkUSA
  5. 5.Division of Cardiology, Department of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  6. 6.Astellas Pharma Global Development, IncNorthbrookUSA
  7. 7.Department of Radiology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  8. 8.Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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