Implications of Sociodemographic and Clinical Factors Associated with Completion of Cardiac Stress Tests

Abstract

Background: Though cardiac stress tests have long been the standard of care for initial evaluation of cardiac symptoms, our institution, along with others, has noted high rates of incomplete tests.

Objective: To identify sociodemographic factors associated with the completion of cardiac stress tests and to assess the value of completed tests.

Design & participants: We conducted a retrospective chart review evaluating 150 patients with cardiac stress tests orders placed in 1 urban hospital-based primary care practice from 1/1/2018-12/31/2021.

Main measures: Our primary outcome was the completion of the stress test. We examined rates of completion based on sociodemographic factors including age, gender, race, language, and social vulnerability, markers of chronic illness, risk of atherosclerotic cardiovascular disease, and pretest probability of coronary artery disease.

Key results: In a multivariable adjusted model, female gender (OR:0.43 [0.18-1.00]), Black race (OR:0.26 [0.11-0.61]), and dyslipidemia (OR:0.27 [0.090-0.78]) were associated with lower test completion rates. We found no relationship between the likelihood of test completion and pretest probability. In an analysis of tests with low pretest probability, 100% of low-risk stress tests were negative; had any of those tests been positive the highest positive predictive value would have been 25%.

Conclusions: Test completion rates were significantly lower for individuals with female gender, Black race, and a diagnosis of dyslipidemia, highlighting inequities in the completion rates for a potentially lifesaving test. In addition, a substantial number of ordered tests were low risk and low value, highlighting areas of opportunity by advancing the value of cardiovascular care delivered.

Keywords: Academic Medical Centers; Cardiac Stress Test; Diagnostic Errors; Diagnostic Tests; Patient Safety; Primary Health Care; Quality Improvement; Retrospective Studies; Sociodemographic Factors.