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Cost and appropriateness of radionuclide exercise stress testing by cardiologists and non-cardiologists
J H Stein1, E F Uretz, J E Parrillo
1Department of Medicine, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA.
Insights
Non-cardiologists frequently ordered unnecessary radionuclide exercise stress tests, increasing healthcare costs. Referring patients to a cardiologist before testing could improve cost-effectiveness and reduce unindicated procedures.
Area of Science:
- Cardiology
- Health Economics
Background:
- The cost-effectiveness of diagnostic evaluations by generalists versus specialists remains largely unexplored.
- Radionuclide exercise stress testing is a common diagnostic tool for coronary artery disease.
Purpose of the Study:
- To evaluate the indications and financial impact of radionuclide exercise stress testing performed by cardiologists and non-cardiologists.
- To assess the cost-effectiveness of referring patients to a cardiologist prior to ordering stress tests.
Main Methods:
- Retrospective analysis of 1,902 adults undergoing radionuclide exercise stress testing.
- Evaluation of test indications based on published reports and practice guidelines.
- Calculation of cost and charge savings associated with a pre-referral strategy to a cardiologist.
Main Results:
- Non-cardiologists ordered significantly more unindicated tests (69.6%) compared to cardiologists (36.2%).
- Unindicated tests resulted in excess costs of $591,384 and excess charges of $1,082,400.
- Referral to a cardiologist could have saved $63,257 in costs and $169,800 in charges.
Conclusions:
- Both cardiologists and non-cardiologists overutilized radionuclide exercise stress tests.
- Non-cardiologists demonstrated a higher likelihood of ordering unindicated tests.
- A strategy of referral to a cardiologist before ordering stress tests may be a cost-effective approach.
Abstract:
The hypothesis that a diagnostic evaluation performed by a generalist is less expensive than that performed by a specialist is untested. We retrospectively evaluated the indications and financial ramifications of radionuclide exercise stress testing by cardiologists and noncardiologists in 1,902 consecutive adults with normal resting electrocardiograms. Subjects completed radionuclide exercise tests for the diagnosis or management of coronary artery disease during a 14-month period. Tests were considered "indicated" or "not indicated" based on criteria determined from published reports and established practice guidelines. Savings in costs and charges were determined for a strategy of referral to a cardiologist before ordering tests. Non-cardiologists ordered more tests that were not indicated than cardiologists (69.6% vs 36.2%, chi-square = 209.07, p < 0.00001). Non-cardiologists also ordered tests that were not indicated in patients with (chi-square = 110.02, p < 0.00001) and without (chi-square = 110.02, p < 0.00001) and without (chi-square = 45.44, p < 0.00001) chest pain. Tests that were not indicated resulted in excess costs of $591,384 and excess charges of $1,082,400. Referral to a cardiologist before ordering tests could have saved $63,257 in costs and $169,800 in charges. Both cardiologists and non-cardiologists overutilized radionuclide exercise stress test; however, non-cardiologists were more likely to order tests that were not indicated. A strategy of referral to a cardiologist before ordering tests may be cost-effective in this population.