Key result
Physician-level factors drove up to 59.0% of variation in initial stress testing, with cardiovascular specialists sevenfold more likely to order an initial MPI than a GXT (OR 7.35; 95% CI 5.38-10.03).
Why the study?
The study was conducted to identify patient-, physician-, and geographic-level factors associated with variation in initial stress testing strategy among patients evaluated for chest pain.
What patient, physician, and geographic factors predict the choice of initial cardiac stress testing strategy in patients evaluated for chest pain?
Cohort (n=103,368)
Yes
What patient, physician, and geographic factors predict the choice of initial cardiac stress testing strategy in patients evaluated for chest pain?
Significant variability in initial stress testing strategy for chest pain is largely driven by physician-level factors, highlighting a target for educational campaigns to improve guideline adherence.
Physician-driven variation in stress testing may reflect nonclinical factors; leaves open whether education can reduce unwarranted differences in chest pain evaluation.
OBJECTIVES: To identify patient, physician and geographic level factors that are associated with variation in initial stress testing strategy in patients evaluated for chest pain. DESIGN: Retrospective cohort study. SETTING: Population-based study of patients undergoing evaluation for chest pain in Ontario, Canada between 1 January 2011 and 31 March 2018. PARTICIPANTS: 103 368 patients who underwent stress testing (graded exercise stress testing (GXT), stress echocardiography (stress echo) or myocardial perfusion imaging (MPI)) following evaluation for chest pain. PRIMARY AND SECONDARY OUTCOME MEASURES: To identify the patient, physician and geographic level factors associated with variation in initial test selection, we fit two separate 2-level hierarchical multinomial logistic regression models for which the outcome was initial stress testing strategy (GXT, MPI or stress echo). RESULTS: There was significant variability in the initial type of stress test performed, with approximately 50% receiving a GXT compared with approximately 36% who received MPI and 14% who received a stress echo. Physician-level factors were key drivers of this variation, accounting for up to 59.0% of the variation in initial testing. Physicians who graduated medical school >30 years ago were approximately 45% more likely to order an initial stress echo (OR 1.45, 95% CI 1.17 to 1.80) than a GXT. Cardiovascular disease specialists were approximately sevenfold more likely to order an initial MPI (OR 7.35, 95% CI 5.38 to 10.03) than a GXT. Patients aged >70 years were approximately fivefold more likely to receive an MPI (OR 4.74, 95% CI 4.42 to 5.08) and approximately 26% more likely to receive a stress echo (OR 1.26, 95% CI 1.15 to 1.38) than a GXT. CONCLUSIONS: We report significant variability in initial stress testing strategy in Ontario. Much of that variability was driven by physician-level factors that could potentially be addressed through educational campaigns geared at reducing this variability and improving guideline adherence.
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Roifman et al. (2022) conducted a cohort in Chest pain (n=103,368). Physician and patient factors vs. Graded exercise stress testing (GXT) was evaluated on Initial stress testing strategy (GXT, MPI or stress echo). Physician-level factors drove up to 59.0% of variation in initial stress testing, with cardiovascular specialists sevenfold more likely to order an initial MPI than a GXT (OR 7.35; 95% CI 5.38-10.03).
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