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. 2021 Oct;28(5):1988-1997.
doi: 10.1007/s12350-019-01955-x. Epub 2019 Nov 18.

Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria

Sanjay Divakaran  1   2 , Avinainder Singh  3 , Ersilia M DeFilippis  4 , Timothy W Churchill  5 , Sarah Cuddy  1 , Yin Ge  1 , Ivan K Ip  6 , Wunan Zhou  1 , Hicham Skali  1   2 , Viviany R Taqueti  1 , Sharmila Dorbala  1 , James Spalding  6 , Yanqing Xu  6 , Ramin Khorasani  7 , Marcelo F Di Carli  1   2 , Maria A Yialamas  8 , Ron Blankstein  9   10 ; Brigham and Women’s Hospital Internal Medicine Residency
Affiliations

Appropriateness of inpatient stress testing: Implications for development of clinical decision support mechanisms and future criteria

Sanjay Divakaran et al. J Nucl Cardiol. 2021 Oct.

Abstract

Background: An upcoming national mandate will require consultation of appropriate use criteria (AUC) through a clinical decision support mechanism (CDSM) for advanced imaging. We aimed to evaluate our current ability to ascertain test appropriateness.

Methods: We prospectively collected data on 288 consecutive stress tests and coronary computed tomography angiography studies for medical inpatients. Study appropriateness was determined independently by two physicians using the 2013 Multimodality AUC.

Results: The median age of the study population was 66 years [interquartile range (IQR) 56, 75], 40.8% were female, and 52.8% had a history of coronary artery disease. Review of the electronic health record (EHR) alone was sufficient to deem appropriateness for 87.2% of cases. The most common reason it was insufficient was inability to determine if the patient could exercise (59.5%). After reviewing the EHR and pilot CDSM data together, appropriateness could be determined for 95.8% of the cases. The most common reason appropriateness could not be determined was that the exam indication was not addressed by an AUC criterion (83.3%).

Conclusion: In preparing for the mandate, it will be important for future CDSM to obtain information on the patient's ability to exercise and for future AUC to include additional indications that are not currently addressed.

Keywords: CAD; Exercise testing; Multimodality; Others.

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Figures

Figure 1.
Figure 1.. Questions Asked at Time of Order Entry via Pilot Clinical Decision Support Mechanism.
CAD = coronary artery disease. HR = heart rate.
Figure 2.
Figure 2.. Study Type Frequency.
A. Study Type Frequency - All Patients. B. Study Type Frequency - By Absence or Presence of Known Coronary Artery Disease. CTA = computed tomography angiography. ECG = electrocardiogram. ETT = exercise treadmill testing. MRI = magnetic resonance imaging. PET = positron emission tomography. SPECT = single-photon emission computed tomography.
Figure 2.
Figure 2.. Study Type Frequency.
A. Study Type Frequency - All Patients. B. Study Type Frequency - By Absence or Presence of Known Coronary Artery Disease. CTA = computed tomography angiography. ECG = electrocardiogram. ETT = exercise treadmill testing. MRI = magnetic resonance imaging. PET = positron emission tomography. SPECT = single-photon emission computed tomography.
Figure 3.
Figure 3.. Appropriateness of Studies Ordered.
A. Appropriateness of Studies Ordered Using the Electronic Health Record Alone. B. Appropriateness of Studies Ordered Using Both the Electronic Health Record and Data from the Pilot Clinical Decision Support Mechanism.
Figure 3.
Figure 3.. Appropriateness of Studies Ordered.
A. Appropriateness of Studies Ordered Using the Electronic Health Record Alone. B. Appropriateness of Studies Ordered Using Both the Electronic Health Record and Data from the Pilot Clinical Decision Support Mechanism.
Figure 4.
Figure 4.. Reasons Appropriateness Could Not Be Determined.
A. All Reasons Electronic Health Record Alone Was Unable to Deem Appropriateness (Total Cases n=37). B. All Reasons Electronic Health Record and Data from Pilot Clinical Decision Support Mechanism Together Were Unable to Deem Appropriateness (Total Cases n=12). AUC = appropriate use criteria.
Figure 4.
Figure 4.. Reasons Appropriateness Could Not Be Determined.
A. All Reasons Electronic Health Record Alone Was Unable to Deem Appropriateness (Total Cases n=37). B. All Reasons Electronic Health Record and Data from Pilot Clinical Decision Support Mechanism Together Were Unable to Deem Appropriateness (Total Cases n=12). AUC = appropriate use criteria.
Figure 5.
Figure 5.. Opportunities for Enhancing Effectiveness of Clinical Decision Support Mechanisms and Future Appropriate Use Criteria.
AUC = appropriate use criteria. CDSM = clinical decision support mechanism.
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