Underuse and overuse of diagnostic testing for coronary artery disease in patients presenting with new-onset chest pain.
OBJECTIVE
To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests.


METHODS
We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire.


RESULTS
Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4).


CONCLUSIONS
Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.
Carlisle
D M
DM
RAND, Santa Monica, CA, USA.
Leape
L L
LL
Bickel
S
S
Bell
R
R
Kamberg
C
C
Genovese
B
B
French
W J
WJ
Kaushik
V S
VS
Mahrer
P R
PR
Ellestad
M H
MH
Brook
R H
RH
Shapiro
M F
MF
D000328:Adult; D017677:Age Distribution; D000368:Aged; D002637:Chest Pain / Q000209:etiology*; D003327:Coronary Disease / Q000150:complications / Q000175:diagnosis*; D003937:Diagnosis, Differential; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data*; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006302:Health Services Research; D006786:Hospitals, Urban / Q000706:statistics & numerical data; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D015141:Los Angeles / Q000453:epidemiology; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D012189:Retrospective Studies; D017678:Sex Distribution; D012923:Social Class; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D019564:Unnecessary Procedures / Q000706:statistics & numerical data