Table 2 –
Significant Factors Associated with Preoperative Cardiac Testing
| LEVEL | RESULTS | INTERPRETATION |
|---|---|---|
| Patient | ||
| Female gender | Fewer stress tests (Chan,32 Ellenbogen,38 Rubin40); fewer catheterizations (Ellenbogen38); more EKGs (Ganguli24), more stress tests (Sheffield27) | Generally, women received less testing |
| Older age | More EKGs and cascade events (Ganguli24); more echos (Adair,22 Ellenbogen,38 Marcantonio26); more stress tests (Charlesworth,36 Ellenbogen,38 Rubin,40 Valle29); more cardiac catheterizations (Ellenbogen38); more preoperative cardiac testing (King31) | Older age strongly associated with more testing. |
| White race | Fewer EKGs (Ganguli24), more EKGs (Pickering30) | Not a clear association between race or ethnicity and testing |
| Hispanic ethnicity | More EKGs (Ganguli24), fewer EKGs (Pickering30), more echos (Sinvani28) | |
| Area of residence | ||
| Urban area | More EKGs (Ganguli24) | Association between urban/large metro areas and more EKGs |
| Large metro (vs small metro) | More EKGs (Pickering30) | |
| Primary payer | ||
| Medicare (vs commercial) | More cardiac testing (Colla23) | Association of government-sponsored insurance with more testing and capitated insurance plans with less testing |
| Medicaid (vs commercial) | More echos and stress tests (Charlesworth36) | |
| Medicaid enrollment | More EKGs (Ganguli24) | |
| Commercial insurance (vs other insurance types) | Fewer stress tests and catheterizations (Ellenbogen38) | |
| Capitated (vs non- capitated) insurance plan | Fewer stress tests (Rubin40) | |
| Increasing comorbidity | ||
| Elixhauser Comorbidity Score | More EKGs (Ganguli24, Pickering30), more echos, stress tests, and catheterizations (Ellenbogen38), more cascade events (Ganguli24) | Strong association between higher levels of comorbidity and more testing |
| Charlson Comorbidity Index | More EKGs (Riggs42), more echos (Adair,22 Charlesworth,36 Riggs,42 Sinvani28), more stress tests (Charlesworth,36 Riggs,42 Sheffield27) | |
| ASA Physical Classification System | More echos (Marcantonio26), more preoperative cardiac testing (King31) | |
| MICA Score | More stress tests (Pappas35) | |
| RCRI | More cardiac testing (King31), more EKGs (Riggs42), more echos (Riggs42), more stress tests (Pappas,35 Riggs,42 Rubin,40 Valle29) | |
| More cascade events | More EKGs (Ganguli,24 Pickering30) | Strong evidence that low-value preoperative EKGs can lead to are associated with downstream testing |
| Provider | ||
| Preoperative clinic visit (vs primary care visit) before surgery | More EKGs and stress tests (Sigmund43) | Preoperative clinic visit (vs primary care visit) and preoperative cardiology visit associated with more testing |
| Preoperative cardiology referral | More preoperative cardiac tests (King31) | |
| Tendency of internal medicine physicians working at a preoperative evaluation clinic to order more tests | More stress tests (Pappas35) | Significant impact of preoperative clinic provider practice habits on volume of testing |
| Admitted to a medicine service (vs surgery service) | More echos (Sinvani28) | Admission to a medical (vs surgical) service associated with more echos |
| Transitioning from multiple specialties to just hospitalist deciding if echo is needed | Fewer echos (Esper46) | QI initiative streamlining decision on echo to only hospitalist associated with less testing |
| System | ||
| Increasing regional cardiologist density | More EKGs and more cascade events after EKG (Ganguli24), more stress tests (Sheffield27) | Regions with more cardiologists per capita, higher spending, or greater populations had more testing |
| Greater spending per Medicare beneficiary at HRR level | More stress tests (Sheffield27) | |
| Location in more populated MSA | More stress tests (Sheffield27) | |
| Higher VA Facility complexity level | More EKGs (Pickering30) | Higher health system patient complexity associated with more testing# |
| Higher overall RCRI scores for surgical patients at health system | More stress tests (Valle29) | |
| Location | Midwest and West (vs South and Northeast) associated with more EKGs (Pickering30); Midwest, Mountain West, and Northeast (vs Pacific Northwest) associated with more stress tests (Sheffield27); Washington state (vs Maryland and New Jersey) associated with fewer stress tests and catheterizations (Ellenbogen38) | Multiple studies showed regional variation in testing intensity, but with somewhat conflicting findings |
| Larger hospital or health system size | Fewer EKGs (Pickering30), more stress tests (Sheffield27), more catheterizations (Ellenbogen38), fewer echos (Ellenbogen38) | Does not seem to be a clear relationship between hospital/health system size and testing intensity |
| Community hospital (vs tertiary care center) | More echos (Sinvani28) | Community hospitals (vs tertiary care centers) associated with more echos |
| Implementation of preoperative testing guidelines and algorithms with or without educational curriculum | Fewer EKGs (Aviki,45 Langell,48 Mafi*,44 Nelson49) | Multiple successful QI intitatives to decrease EKG overutilization |
| Publication of 2002 ACC/AHA Perioperative Guidelines | Fewer EKGs (Sigmund43) | Publication of 2002 guidelines associated with fewer EKGs |
| Higher proportion of elective inpatient surgeries to outpatient surgeries | More stress tests (Valle29) | More elective inpatient surgeries relative to outpatient surgeries associated with mores stress tests |
Abbreviations:
ACC – American College of Cardiology
AHA – American Heart Association
ASA – American Society of Anesthesiologists
MICA – Myocardial Infarction or Cardiac Arrest
MSA – Metropolitan Statistical Area
QI – Quality Improvement
RCRI – Revised Cardiac Risk Index
Not all references are cited in this table because not all had significant findings for a patient, provider, or system level factor
Significance is defined as p<0.05
* -
Mafi study had a large educational component
# -
Both of these studies were done on VA populations