Author + information
- Received March 13, 2012
- Revision received June 26, 2012
- Accepted July 19, 2012
- Published online October 1, 2012.
- Jerome J. Federspiel, AB⁎,†,‡,
- Daniel W. Mudrick, MD, MPH§∥,
- Bimal R. Shah, MD, MBA⁎,§,
- Sally C. Stearns, PhD†,
- Frederick A. Masoudi, MD, MSPH¶,
- Patricia A. Cowper, PhD⁎,
- Cynthia L. Green, PhD⁎ and
- Pamela S. Douglas, MD⁎,§,⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Pamela S. Douglas, Duke Clinical Research Institute, 2400 Pratt Street, Durham, North Carolina 27703
Objectives We evaluated temporal trends and geographic variation in choice of stress testing modality after percutaneous coronary intervention (PCI), as well as associations between modality and procedure use after testing.
Background Stress testing is frequently performed post-PCI, but the choices among available modalities (electrocardiography only, nuclear, or echocardiography; pharmacological or exercise stress) and consequences of such choices are not well characterized.
Methods CathPCI Registry® data were linked with identifiable Medicare claims to capture stress testing use between 60 and 365 days post-PCI and procedures within 90 days after testing. Testing rates and modality used were modeled on the basis of patient, procedure, and PCI facility factors, calendar quarter, and Census Divisions using Poisson and logistic regression. Post-test procedure use was assessed using Gray's test.
Results Among 284,971 patients, the overall stress testing rate after PCI was 53.1 per 100 person-years. Testing rates declined from 59.3 in quarter 1 (2006) to 47.1 in quarter 4 (2008), but the relative use of modalities changed little. Among exercise testing recipients, adjusted proportions receiving electrocardiography-only testing varied from 6.8% to 22.8% across Census Divisions; and among exercise testing recipients having an imaging test, the proportion receiving echocardiography (versus nuclear) varied from 9.4% to 34.1%. Post-test procedure use varied among modalities; exercise electrocardiography-only testing was associated with more subsequent stress testing (13.7% vs. 2.9%; p < 0.001), but less catheterization (7.4% vs. 14.1%; p < 0.001) than imaging-based tests.
Conclusions Modest reductions in stress testing after PCI occurring between 2006 and 2008 cannot be ascribed to trends in use of any single modality. Additional research should assess whether this trend represents better patient selection for testing or administrative policies (e.g., restricted access for patients with legitimate testing needs). Geographic variation in utilization of stress modalities and differences in downstream procedure use among modalities suggest a need to identify optimal use of the different test modalities in individual patients.
This study was sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, Rockville, Maryland, as part of the Cardiovascular Consortium and funded under project 24-DKE-3 and work assignment number HHSA290-2005-0032-I-TO4-WA3 as part of the Developing Evidence to Inform Decisions About Effectiveness program. The authors of this manuscript are responsible for its content. Statements in the manuscript should not be construed as endorsement by the U.S. Department of Health and Human Services. This study was also partially supported by the National Heart, Lung, and Blood Institute (F30-HL110483) and by the National Institute for General Medical Sciences (T32-GM008719). The contents of the manuscript are the responsibility of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute or the National Institute for General Medical Sciences. This study was supported by the National Cardiovascular Data Registry (NCDR), American College of Cardiology (ACC); the views expressed represent those of the authors, and do not necessarily represent the official views of the NCDR or of its associated professional societies identified at www.ncdr.com. Dr. Shah reports salary support from AHRQ (significant), and consulting fees from Castlight (modest). Dr. Masoudi reports salary support from the ACC (significant), and grant support from the ACC and AHRQ (significant). All other authors have reported they have no relationships relevant to the contents of this paper to disclose.
- Received March 13, 2012.
- Revision received June 26, 2012.
- Accepted July 19, 2012.
- American College of Cardiology Foundation