title: Stress Testing After Percutaneous Coronary Intervention in the Veterans Affairs HealthCare System: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.
abstract: BACKGROUND
  Stress testing after percutaneous coronary intervention (PCI) in fee-for-service settings is common and rates vary by hospital. Rates of stress testing after PCI within integrated healthcare systems, such as the Veterans Affairs (VA) are unknown.
  
  
  RESULTS
  We evaluated all VA patients who underwent PCI from October 2007 through June 2010. To avoid the influence of Medicare eligibility on rates of stress testing use in the VA, we excluded Medicare eligible patients during the follow-up period. Hospital-level variation in risk-standardized rates of stress testing and the association with 1-year mortality and myocardial infarction was determined from Markov chain Monte Carlo methods. Among 10 293 patients undergoing PCI at 55 VA hospitals, 2239 (21.8%) had a stress test performed within 1 year of PCI and 3902 (37.9%) within 2 years. Most stress tests after PCI were performed with nuclear imaging (79.8%). The hospital-level risk-standardized rate of stress testing differed significantly from the average at 14 hospitals, with 8 (14.5%) hospitals significantly below and 6 (10.9%) hospitals significantly above the average stress testing rate. Hospital-level risk-standardized stress testing rates were not significantly correlated with risk-standardized mortality (Spearman ρ=-0.24; P=0.08) or myocardial infarction rates (Spearman ρ=0.20; P=0.14).
  
  
  CONCLUSIONS
  In the VA, nearly 40% of patients underwent stress testing in the 2 years after PCI, which is a third less than published studies from other healthcare systems. However, stress testing rates varied across VA hospitals, suggesting opportunities to optimize the use of stress testing are still present in integrated healthcare systems.
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.). Steven.Bradley@va.gov.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: Edward
authors.initials: E
authors.lastname: Hess
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: David E
authors.initials: DE
authors.lastname: Winchester
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: Jeremy B
authors.initials: JB
authors.lastname: Sussman
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: Vikas
authors.initials: V
authors.lastname: Aggarwal
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: Anna E
authors.initials: AE
authors.lastname: Barón
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.affiliation: From the VA Eastern Colorado Health Care System, Denver (S.M.B., E.H., T.M.M., A.E.B., J.S.R., P.M.H.); University of Colorado School of Medicine, Aurora (S.M.B., T.M.M., A.E.B., J.S.R., P.M.H.); Colorado Cardiovascular Outcomes Research Consortium, Denver (S.M.B., E.H., T.M.M., J.S.R., P.M.H.); Malcom Randall VA Medical Center, Gainesville, FL (D.E.W.); University of Florida College of Medicine, Gainesville (D.E.W.); VA Ann Arbor Healthcare System, Ann Arbor, MI (J.B.S.); and Temple University School of Medicine, Philadelphia, PA (V.A.).
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
mesh_terms: D000368:Aged; D002423:Cause of Death / Q000639:trends; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006787:Hospitals, Veterans; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects*; D011183:Postoperative Complications / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans
keywords: coronary artery disease; exercise test; myocardial infarction; percutaneous coronary intervention; perfusion imaging; practice pattern variations