[Evaluation of the appropriateness of prescribing Holter dynamic electrocardiography]
Alberto Genovesi Ebert1, Mirco Magnani, Michele Galli
1U.O. di Cardiologia e Unità Coronarica Ospedali Riuniti Azienda USL 6 Area Livornese Viale Alfieri, 36, 57100 Livorno. a.genovesi@tin.it
Insights
Approximately 40% of Holter monitoring tests were inappropriately prescribed in Italy. Appropriate Holter monitoring indications led to more abnormal and useful results, with cardiologists prescribing more appropriate tests.
Area of Science:
- Cardiology
- Medical Diagnostics
- Health Services Research
Background:
- Assessed the appropriateness of Holter monitoring indications in ambulatory patients across 21 laboratories in Tuscany and Umbria, Italy.
- Focused on a 4-week period to capture current prescribing practices.
Purpose of the Study:
- To evaluate the appropriateness of Holter monitoring indications based on established cardiology guidelines.
- To determine the relationship between indication appropriateness, prescribing physician specialty, test results, and clinical utility.
Main Methods:
- Collected data on 863 Holter monitoring prescriptions, including indication appropriateness (Class I, II, III), prescribing physician (cardiologist vs. non-cardiologist), test results (normal/abnormal), and clinical utility (useful/useless).
- Analyzed data according to Italian Federation of Cardiology guidelines.
Main Results:
- 59.6% of indications were appropriate (Class I), 11.7% doubtfully appropriate (Class II), and 28.7% inappropriate (Class III).
- Appropriate indications (Class I) were more frequently associated with abnormal (37.9%) and useful (59.2%) results compared to inappropriate ones (Class III: 24.5% abnormal, 21% useful).
- Cardiologist-prescribed tests showed significantly higher appropriateness (67.6% Class I), abnormality rates (40%), and clinical utility (59.8%) than non-cardiologist prescriptions.
Conclusions:
- Nearly 40% of Holter monitoring exams in the studied regions were deemed inappropriate.
- Appropriately prescribed Holter monitoring tests yield more abnormal and clinically useful findings.
- Cardiologist prescription of Holter monitoring is associated with greater appropriateness, diagnostic yield, and clinical utility.
Background:
We evaluated the appropriateness of indications to Holter monitoring performed on ambulatory patients during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy.
Methods:
We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam.
Results:
We evaluated 863 prescriptions (population: 435 males, 428 females; mean age 64 years, range 15-90 years). The indications to the test were of class I (appropriate) in 59.6%, of class II (doubtfully appropriate) in 11.7%, and of class III (inappropriate) in 28.7% of the cases. In 33% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 37.9% of class I, in 36.7% of class II, and in 24.5% of class III exams (p < 0.05). The exam was considered useful in 46.7% of the cases. In particular, a useful result was found in 59.2% of class I, in 45.5% of class II, and in 21% of class III exams (p < 0.05). Cardiologists prescribed 373/863 tests (43.2%). Their indications were of class I in 67.6%, of class II in 12% and of class III in 24% of the cases vs 53.7, 11.4 and 34.9% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 40% of cardiologist- vs 27.6% of non-cardiologist-prescribed examinations (odds ratio 1.74, 95% confidence interval 1.31-2.32; p < 0.05); similarly, clinically useful information could be derived from 59.8% of cardiologist- vs 36.7% of non-cardiologist-prescribed examinations (odds ratio 2.56, 95% confidence interval 1.94-3.37; p < 0.05).
Conclusions:
In Tuscany and Umbria, Italy, about 40% of Holter exams are inappropriate; appropriately prescribed exams are more often abnormal and useful; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.
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