More appropriate use of cardiac stress testing with imaging could reduce health costsOctober 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."
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:
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).
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.
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.
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.
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.
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.
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.
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.
A history of gallstone disease was linked to a 23 percent increased risk of developing coronary heart disease.
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)
The New York Times bestselling guide to the lifesaving diet that can both prevent and help reverse the effects of heart disease
Based on the groundbreaking results of his twenty-year nutritional study, Prevent and Reverse Heart Disease by Dr. Caldwell Esselstyn illustrates that a plant-based, oil-free diet can not only prevent the progression of heart disease but can also reverse its effects. Dr. Esselstyn is an internationally known surgeon, researcher and former clinician at the Cleveland Clinic and a featured expert in the acclaimed documentary Forks... View Details
Pathophysiology of Heart Disease: A Collaborative Project of Medical Students and Faculty
by Leonard S. Lilly MD (Author)
Publisher’s Note: Products purchased from 3rd Party sellers are not guaranteed by the Publisher for quality, authenticity, or access to any online entitlements included with the product.
Specifically designed to prepare medical students for their initial encounters with patients with heart disease, this award-winning text bridges basic cardiac physiology with clinical care. Written by internationally recognized Harvard Medical School faculty and select medical students, Pathophysiology of Heart Disease, Sixth Edition provides a solid foundation of knowledge... View Details
The End of Heart Disease: The Eat to Live Plan to Prevent and Reverse Heart Disease
by Dr. Joel Fuhrman (Author)
The New York Times bestselling author of Eat to Live, Super Immunity, The End of Diabetes, and The End of Dieting presents a scientifically proven, practical program to prevent and reverse heart disease, the leading cause of death in America—coinciding with the author’s new medical study revealing headline-making findings.
Dr. Joel Fuhrman, one of the country’s leading experts on preventative medicine, offers his science-backed nutritional plan that addresses the leading cause of death in America: heart disease. An expert in the science of food, Dr.... View Details
The Simple Heart Cure: The 90-Day Program to Stop and Reverse Heart Disease
by Chauncey Crandall (Author)
Heart disease kills more people than any other medical condition. And no one is more aware of this than top cardiologist Dr. Chauncey Crandall, who has performed over 40,000 heart procedures during his career.
In his new book, The Simple Heart Cure, you’ll find this top doc’s groundbreaking approach to preventing and reversing heart disease an approach honed by his study of foreign cultures free of heart disease and decades of experience helping patients achieve a healthier heart at any age.
Dr. Crandall is living proof of his program’s success. At the age of... View Details
The Prevent and Reverse Heart Disease Cookbook: Over 125 Delicious, Life-Changing, Plant-Based Recipes
by Ann Crile Esselstyn (Author), Jane Esselstyn (Author)
The long-awaited cookbook companion to the revolutionary New York Times bestseller Prevent and Reverse Heart Disease.
“I hope you'll treat yourself to one of these recipes and just open that door. I guarantee you won't close it!"
—Samuel L. Jackson
Hundreds of thousands of readers have been inspired to turn their lives around by Dr. Caldwell B. Esselstyn’s Jr.’s bestseller, Prevent and Reverse Heart Disease. The plant-based nutrition plan Dr. Esselstyn advocates based on his twenty-year nutritional study—the most... View Details
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)
The Ornish Diet has been named the “#1 best diet for heart disease” by U.S. News & World Report for seven consecutive years!
Dr. Dean Ornish is the first clinician to offer documented proof that heart disease can be halted, or even reversed, simply by changing your lifestyle. Based on his internationally acclaimed scientific study, which has now been ongoing for years, Dr. Ornish's program has yielded amazing results. Participants reduced or discontinued medications; they learned how to lower high blood pressure; their chest pain diminished or disappeared; they felt... View Details
What Your Doctor May Not Tell You about Heart Disease
by Mark Houston (Author)
Coronary heart disease has long been the number one killer in this country, and for decades, we have been told about five basic risk factors: elevated cholesterol, high blood pressure, diabetes, obesity, and smoking. But the truth is that heart disease is much more complex-- with close to 400 risk factors!
In this innovative guide, Dr. Mark Houston helps readers discover the causes of heart disease, how to prevent and treat its debilitating effects via nutrition, nutritional supplements, exercise, weight management, and lays to rest to various myths (cholesterol is not the... View Details
The 30-Day Heart Tune-Up: A Breakthrough Medical Plan to Prevent and Reverse Heart Disease
by Steven Masley (Author), Douglas D. Schocken (Foreword)
THE 30-DAY HEART TUNE-UP takes readers step by step through a revolutionary program to tune up their hearts, energy, waistlines, and sex lives, with 60 delicious recipes to help jump-start a heart-healthy diet. Cardiovascular disease is the #1 killer of Americans today. But, the good news is that everyone-regardless of size, genetics, gender, or age-can treat arterial plaque and prevent heart attacks and strokes with this book. The keys to the program are shrinking arterial plaque, improving circulation, and strengthening your heartbeat. The tools in this book include... View Details
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 2-Volume Set, 11e
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)
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)
While most books focus solely on the role of cholesterol in heart disease, Reverse Heart Disease Now draws on new research that points to the surprising other causes. Two leading cardiologists draw on their collective fifty years of clinical cardiology research to show you how to combine the benefits of modern medicine, over-the-counter vitamins and supplements, and simple lifestyle changes to have a healthy heart. View Details