Nav: Home

More appropriate use of cardiac stress testing with imaging could reduce health costs

October 08, 2014

New York City - October 8, 2014 - In a new study recently published in the Annals of Internal Medicine, researchers at NYU Langone Medical Center concluded that overuse of cardiac stress testing with imaging has led to rising healthcare costs and unnecessary radiation exposure to patients.

In what is believed to be the first comprehensive examination of trends in cardiac stress testing utilizing imaging, researchers also showed that there are no significant racial or ethnic health disparities in its use. They also made national estimates of the cost of unnecessary cardiac stress testing with imaging and the health burden of this testing, in terms of cancer risk due to radiation exposure.

Cardiac stress testing, particularly with imaging, has been the focus of debate about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure. Joseph Ladapo, MD, PhD, assistant professor in the Departments of Medicine and Population Health at NYU Langone, and the lead author of the study, and colleagues wanted to determine whether U.S. trends in cardiac stress testing with imaging may be attributable to population shifts in demographics, risk factors, and provider characteristics, and to evaluate whether racial/ethnic disparities exist in physician decision making.

They designed their study utilizing data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2010. Patients chosen for the study were adults without coronary heart disease who were referred for cardiac stress tests.

Between 1993 to 1995 and 2008 to 2010, the annual number of ambulatory visits in the U.S. in which a cardiac stress test was ordered or performed increased by more than 50%. Cardiac stress tests with imaging comprised a growing portion of all of these tests -- increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6%--or one million tests--were probably inappropriate, the researchers concluded, with associated annual costs and harms of $501 million and 491 future cases of cancer.

The authors also concluded that there was no evidence of a lower likelihood of black patients receiving a cardiac stress test with imaging (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than their white counterparts -- although some modest evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).

The investigators concluded that the national growth in cardiac stress testing can be attributed largely to population and provider characteristics -- but the use of imaging cannot. Physician decision making about cardiac stress testing also does not result in racial/ethnic disparities in cardiovascular disease.

"Cardiac stress testing is an important clinical tool," says Dr. Ladapo, "but we are over using imaging for reasons unrelated to clinical need. This is causing preventable harm and increasing healthcare costs.

"Reducing unnecessary testing also will concomitantly reduce the incidence of radiation related cancer," he adds. "We estimate that about 500 people get cancer each year in the US from radiation received during a cardiac stress test when, in fact, they most probably didn't need any radiological imaging in the first place. While this number might seem relatively small, we must remember that 'first, do no harm' is one of the guiding principles in medicine."

So what can be done to reduce unnecessary cardiac stress testing with imaging? "More efforts, such as clinical decision support, are needed to reduce unnecessary cardiac stress testing," Dr. Ladapo concludes, suggesting greater use of stress testing without radiological imaging, such as regular exercise treadmill tests or stress testing with ultrasound imaging as opposed to CT imaging.

As to the reason why certain racial and ethnic minorities have poorer rates of treatment for cardiovascular disease and generally have poorer cardiovascular health outcomes compared to white patients, Dr. Ladapo concludes that no one has really explored whether there could be disparities in cardiac stress testing, which is a mainstay of diagnosing patients with heart disease in this country. "If we know that one minority group has a higher incidence of poorer outcomes from heart disease, perhaps we need to examine if they would benefit from more appropriate use of cardiac stress testing," he offers. "Perhaps one contributing reason they have poorer outcomes is because we are not testing them appropriately."
-end-
Video can be found at the following link: https://www.dropbox.com/s/xbtyuhe4nsdtki0/Final%20edited-Dr.%20Joseph%20Ladapo%20annals%20nyu.mp4?dl=0

Additional investigators are Saul Blecker, MD, MHS and Pamela S. Douglas, MD.

Grant Support: By a K23 Career Development Award from the National Heart, Lung, and Blood Institute (grant 1 K23 HL116787-01A1; Dr. Ladapo) and by the National Center for Advancing Translational Sciences (grant KL2 TR000053; Dr. Blecker).

Disclosures: Dr. Ladapo is a consultant to CardioDx, Inc., however he did not receive compensation for this study from either of these sources or any other sources.

About NYU Langone Medical Center

NYU Langone Medical Center, a world-class, patient-centered, integrated academic medical center, is one of the nation's premier centers for excellence in clinical care, biomedical research, and medical education. Located in the heart of Manhattan, NYU Langone is composed of four hospitals--Tisch Hospital, its flagship acute care facility; Rusk Rehabilitation; the Hospital for Joint Diseases, the Medical Center's dedicated inpatient orthopaedic hospital; and Hassenfeld Children's Hospital, a comprehensive pediatric hospital supporting a full array of children's health services across the Medical Center--plus the NYU School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. The Medical Center's tri-fold mission to serve, teach, and discover is achieved 365 days a year through the seamless integration of a culture devoted to excellence in patient care, education, and research. For more information, go to http://www.NYULMC.org, and interact with us on Facebook, Twitter, and YouTube.

NYU Langone Medical Center / New York University School of Medicine

Related Heart Disease Articles:

Where you live could determine risk of heart attack, stroke or dying of heart disease
People living in parts of Ontario with better access to preventive health care had lower rates of cardiac events compared to residents of regions with less access, found a new study published in CMAJ (Canadian Medical Association Journal).
Older adults with heart disease can become more independent and heart healthy with physical activity
Improving physical function among older adults with heart disease helps heart health and even the oldest have a better quality of life and greater independence.
Dietary factors associated with substantial proportion of deaths from heart disease, stroke, and disease
Nearly half of all deaths due to heart disease, stroke, and type 2 diabetes in the US in 2012 were associated with suboptimal consumption of certain dietary factors, according to a study appearing in the March 7 issue of JAMA.
Certain heart fat associated with higher risk of heart disease in postmenopausal women
For the first time, researchers have pinpointed a type of heart fat, linked it to a risk factor for heart disease and shown that menopausal status and estrogen levels are critical modifying factors of its associated risk in women.
Maternal chronic disease linked to higher rates of congenital heart disease in babies
Pregnant women with congenital heart defects or type 2 diabetes have a higher risk of giving birth to babies with severe congenital heart disease and should be monitored closely in the prenatal period, according to a study published in CMAJ.
Novel heart valve replacement offers hope for thousands with rheumatic heart disease
A novel heart valve replacement method is revealed today that offers hope for the thousands of patients with rheumatic heart disease who need the procedure each year.
Younger heart attack survivors may face premature heart disease death
For patients age 50 and younger, the risk of premature death after a heart attack has dropped significantly, but their risk is still almost twice as high when compared to the general population, largely due to heart disease and other smoking-related diseases The risk of heart attack can be greatly reduced by quitting smoking, exercising and following a healthy diet.
Citrus fruits could help prevent obesity-related heart disease, liver disease, diabetes
Oranges and other citrus fruits are good for you -- they contain plenty of vitamins and substances, such as antioxidants, that can help keep you healthy.
Gallstone disease may increase heart disease risk
A history of gallstone disease was linked to a 23 percent increased risk of developing coronary heart disease.
Americans are getting heart-healthier: Coronary heart disease decreasing in the US
Coronary heart disease is one of the leading causes of death in the United States.

Related Heart Disease Reading:

Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure
by Caldwell B. Esselstyn Jr. (Author)

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 2-Volume Set
by Douglas P. Zipes MD (Author), Peter Libby MD PhD (Author), Robert O. Bonow MD MS (Author), Douglas L. Mann MD (Author), Gordon F. Tomaselli MD (Author)

Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty
by Leonard S. Lilly MD (Author)

The Simple Heart Cure: The 90-Day Program to Stop and Reverse Heart Disease
by Chauncey Crandall (Author)

The Prevent and Reverse Heart Disease Cookbook: Over 125 Delicious, Life-Changing, Plant-Based Recipes
by Ann Crile Esselstyn (Author), Jane Esselstyn (Author)

The End of Heart Disease: The Eat to Live Plan to Prevent and Reverse Heart Disease
by Joel Fuhrman M.D. (Author)

The 30-Day Heart Tune-Up: A Breakthrough Medical Plan to Prevent and Reverse Heart Disease
by Steven Masley (Author), Douglas D. Schocken (Foreword)

What Your Doctor May Not Tell You about Heart Disease
by Mark Houston (Author)

Reverse Heart Disease Now: Stop Deadly Cardiovascular Plaque Before It's Too Late
by Stephen T. Sinatra (Author), James C. Roberts (Author), Martin Zucker (Contributor)

Dr. Dean Ornish's Program for Reversing Heart Disease: The Only System Scientifically Proven to Reverse Heart Disease Without Drugs or Surgery
by Dean Ornish (Author)

Best Science Podcasts 2018

We have hand picked the best science podcasts for 2018. Sit back and enjoy new science podcasts updated daily from your favorite science news services and scientists.
Now Playing: TED Radio Hour

The Right To Speak
Should all speech, even the most offensive, be allowed on college campuses? And is hearing from those we deeply disagree with ... worth it? This hour, TED speakers explore the debate over free speech. Guests include recent college graduate Zachary Wood, political scientist Jeffrey Howard, novelist Elif Shafak, and journalist and author James Kirchick.
Now Playing: Science for the People

#486 Volcanoes
This week we're talking volcanoes. Because there are few things that fascinate us more than the amazing, unstoppable power of an erupting volcano. First, Jessica Johnson takes us through the latest activity from the Kilauea volcano in Hawaii to help us understand what's happening with this headline-grabbing volcano. And Janine Krippner joins us to highlight some of the lesser-known volcanoes that can be found in the USA, the different kinds of eruptions we might one day see at them, and how damaging they have the potential to be. Related links: Kilauea status report at USGS A beginner's guide to Hawaii's otherworldly...