title: Application of appropriate use criteria to cardiac stress testing in the hospital setting: limitations of the criteria and areas for improved practice.
abstract: BACKGROUND
  Imaging cardiac stress test use has risen significantly, leading to the development of appropriate use criteria. Prior studies have suggested the rate of inappropriate testing is 13% to 14%, but inappropriate testing in hospitalized patients has not been well studied.
  
  
  OBJECTIVE
  Appropriate use of stress testing in hospitalized patients is not comparable to the ambulatory setting.
  
  
  METHODS
  We studied 459 consecutive patients referred for imaging stress tests (nuclear imaging or stress echocardiography) at a single institution over a 6-month period. Appropriate use was determined by research cardiologists blinded to patient outcomes.
  
  
  RESULTS
  Most tests (68%) were in patients with chest pain or possible acute coronary syndrome (ACS). Another 20% were for preoperative evaluation. The rate of inappropriate testing was 13%. Imaging modality did not correlate with appropriate use. Only 2% of the chest pain or possible ACS were inappropriate, compared to 49% of the preoperative exams (P < 0.001). The most common reason a test was considered inappropriate was for a low-risk patient for preoperative exam (77% of inappropriate tests). Using Thrombolysis in Myocardial Infarction score 0 to define inappropriate testing in the possible ACS cohort might make an additional 27% inappropriate.
  
  
  CONCLUSIONS
  The rate of inappropriate use of cardiac stress testing with imaging in the inpatient setting is similar to that in the ambulatory setting. However, there is wide variation in inappropriate testing based on the indication for the test. Taking risk into consideration in possible ACS patients could result in a larger number of tests being considered inappropriate.
authors.affiliation: Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia.
authors.forename: Zachary M
authors.initials: ZM
authors.lastname: Gertz
authors.forename: William
authors.initials: W
authors.lastname: O'Donnell
authors.forename: Amresh
authors.initials: A
authors.lastname: Raina
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Litwack
authors.forename: Jessica R
authors.initials: JR
authors.lastname: Balderston
authors.forename: Lee R
authors.initials: LR
authors.lastname: Goldberg
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D000368:Aged; D002637:Chest Pain / Q000175:diagnosis*; D025401:Echocardiography, Stress / Q000706:statistics & numerical data*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000706:statistics & numerical data*; D012017:Referral and Consultation; D018570:Risk Assessment; D014505:Urban Population / Q000706:statistics & numerical data