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Frequency of Stress Testing to Document Ischemia Prior to Elective Percutaneous Coronary Intervention
Grace A. Lin, MD, MAS;
R. Adams Dudley, MD, MBA;
F. L. Lucas, PhD;
David J. Malenka, MD;
Eric Vittinghoff, PhD;
Rita F. Redberg, MD, MSc
JAMA. 2008;300(15):1765-1773.
Context Guidelines call for documenting ischemia in patients with stable coronary artery disease prior to elective percutaneous coronary intervention (PCI).
Objective To determine the frequency and predictors of stress testing prior to elective PCI in a Medicare population.
Design, Setting, and Patients Retrospective, observational cohort study using claims data from a 20% random sample of 2004 Medicare fee-for-service beneficiaries aged 65 years or older who had an elective PCI (N = 23 887).
Main Outcome Measures Percentage of patients who underwent stress testing within 90 days prior to elective PCI; variation in stress testing prior to PCI across 306 hospital referral regions; patient, physician, and hospital characteristics that predicted the appropriate use of stress testing prior to elective PCI.
Results In the United States, 44.5% (n = 10 629) of patients underwent stress testing within the 90 days prior to elective PCI. There was wide regional variation among the hospital referral regions with stress test rates ranging from 22.1% to 70.6% (national mean, 44.5%; interquartile range, 39.0%-50.9%). Female sex (adjusted odds ratio [AOR], 0.91; 95% confidence interval [CI], 0.86-0.97), age of 85 years or older (AOR, 0.83; 95% CI, 0.72-0.95), a history of congestive heart failure (AOR, 0.85; 95% CI, 0.79-0.92), and prior cardiac catheterization (AOR, 0.45; 95% CI, 0.38-0.54) were associated with a decreased likelihood of prior stress testing. A history of chest pain (AOR, 1.28; 95% CI, 1.09-1.54) and black race (AOR, 1.26; 95% CI, 1.09-1.46) increased the likelihood of stress testing prior to PCI. Patients treated by physicians performing 150 or more PCIs per year were less likely to have stress testing prior to PCI (AOR, 0.84; 95% CI, 0.77-0.93). No hospital characteristics were associated with receipt of stress testing.
Conclusion The majority of Medicare patients with stable coronary artery disease do not have documentation of ischemia by noninvasive testing prior to elective PCI.
Author Affiliations: Divisions of General Internal Medicine (Dr Lin), Epidemiology and Biostatistics (Dr Vittinghoff), and Cardiology (Dr Redberg), and Institute for Health Policy Studies (Dr Dudley), University of California, San Francisco; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland (Dr Lucas); and Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire (Dr Malenka).
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