title: Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes.
abstract: IMPORTANCE Current guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes. OBJECTIVE To characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease. We excluded patients with AMI. MAIN OUTCOMES AND MEASURES At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures. RESULTS We identified 549,078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8% (10.9%-27.7%); range, 0.2% to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2% vs Q4, 4.9%), and revascularization procedures (Q1, 0.5% vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6% vs Q4, 5.4%) and for angiograms (Q1, 41.2% vs Q4, 38.8%). P <.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P = .51). Approximately 23% of variation in imaging use was attributable to the behavior of individual hospitals. CONCLUSIONS AND RELEVANCE Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography.
authors: Yale University School of Medicine, New Haven, Connecticut.
authors: Kyan C
authors: KC
authors: Safavi
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors: Shu-Xia
authors: SX
authors: Li
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut4Division of Cardiology, Columbia University Medical Center, New York, New York.
authors: Kumar
authors: K
authors: Dharmarajan
authors: Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut6Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors: Arjun K
authors: AK
authors: Venkatesh
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors: Kelly M
authors: KM
authors: Strait
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut7Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut.
authors: Haiqun
authors: H
authors: Lin
authors: Premier Inc, Charlotte, North Carolina.
authors: Timothy J
authors: TJ
authors: Lowe
authors: Division of Cardiology, Department of Medicine, Emory University School of Medicine and Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia.
authors: Reza
authors: R
authors: Fazel
authors: Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan11Department of Internal Medicine, University of Michigan, Ann Arbor 12Center for Healthcare Outcomes and Poli.
authors: Brahmajee K
authors: BK
authors: Nallamothu
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut6Robert Wood Johnson Foundation Cli.
authors: Harlan M
authors: HM
authors: Krumholz
mesh_terms: D015415:Biomarkers / Q000032:analysis; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000628:therapy; D003430:Cross-Sectional Studies; D003952:Diagnostic Imaging / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D014481:United States
chemical_list: D015415:Biomarkers