title: Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.
abstract: BACKGROUND
  Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure.
  
  
  OBJECTIVE
  To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making.
  
  
  METHODS
  Analyses of repeated cross-sectional data.
  
  
  METHODS
  National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010).
  
  
  METHODS
  Adults without coronary heart disease.
  
  
  METHODS
  Cardiac stress test referrals and inappropriate use.
  
  
  RESULTS
  Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).
  
  
  CONCLUSIONS
  Cross-sectional design with limited clinical data.
  
  
  CONCLUSIONS
  National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease.
  
  
  BACKGROUND
  National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Ladapo
authors.forename: Saul
authors.initials: S
authors.lastname: Blecker
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057791:Cardiac Imaging Techniques / Q000706:statistics & numerical data / Q000639:trends; D003327:Coronary Disease / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D003657:Decision Making; D003710:Demography; D005006:Ethnicity; D005080:Exercise Test / Q000706:statistics & numerical data / Q000639:trends*; D019538:Health Care Surveys; D006801:Humans; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012307:Risk Factors; D014481:United States; D055815:Young Adult