title: Appropriate Use of Cardiac Stress Testing with Imaging: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Appropriate use criteria (AUC) for cardiac stress tests address concerns about utilization growth and patient safety. We systematically reviewed studies of appropriateness, including within physician specialties; evaluated trends over time and in response to AUC updates; and characterized leading indications for inappropriate/rarely appropriate testing.
  
  
  METHODS
  We searched PubMed (2005-2015) for English-language articles reporting stress echocardiography or myocardial perfusion imaging (MPI) appropriateness. Data were pooled using random-effects meta-analysis and meta-regression.
  
  
  RESULTS
  Thirty-four publications of 41,578 patients were included, primarily from academic centers. Stress echocardiography appropriate testing rates were 53.0% (95% CI, 45.3%-60.7%) and 50.9% (42.6%-59.2%) and inappropriate/rarely appropriate rates were 19.1% (11.4%-26.8%) and 28.4% (23.9%-32.8%) using 2008 and 2011 AUC, respectively. Stress MPI appropriate testing rates were 71.1% (64.5%-77.7%) and 72.0% (67.6%-76.3%) and inappropriate/rarely appropriate rates were 10.7% (7.2%-14.2%) and 15.7% (12.4%-19.1%) using 2005 and 2009 AUC, respectively. There was no significant temporal trend toward rising rates of appropriateness for stress echocardiography or MPI. Unclassified stress echocardiograms fell by 79% (p = 0.04) with updated AUC. There were no differences between cardiac specialists and internists.
  
  
  CONCLUSIONS
  Rates of appropriate use tend to be lower for stress echocardiography compared to MPI, and updated AUC reduced unclassified stress echocardiograms. There is no conclusive evidence that AUC improved appropriate use over time. Further research is needed to determine if integration of appropriateness guidelines in academic and community settings is an effective approach to optimizing inappropriate/rarely appropriate use of stress testing and its associated costs and patient harms.
authors.affiliation: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Ladapo
authors.affiliation: Department of Population Health and Medicine, New York University School of Medicine, New York, NY, United States of America.
authors.forename: Saul
authors.initials: S
authors.lastname: Blecker
authors.affiliation: New York University School of Medicine, New York, NY, United States of America.
authors.forename: Michael
authors.initials: M
authors.lastname: O'Donnell
authors.affiliation: New York University, New York, NY, United States of America.
authors.forename: Saahil A
authors.initials: SA
authors.lastname: Jumkhawala
authors.affiliation: Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America.
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
mesh_terms: D003327:Coronary Disease / Q000175:diagnosis / Q000000981:diagnostic imaging; D004452:Echocardiography; D005080:Exercise Test; D006801:Humans; D055414:Myocardial Perfusion Imaging; D061214:Patient Safety; D017410:Practice Guidelines as Topic