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Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.

ABSTRACT: Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure.To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making.Analyses of repeated cross-sectional data.National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010).Adults without coronary heart disease.Cardiac stress test referrals and inappropriate use.Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]).Cross-sectional design with limited clinical data.National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease.National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.

SUBMITTER: Ladapo JA

PROVIDER: S-EPMC4335355 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.

Ladapo Joseph A JA Blecker Saul S Douglas Pamela S PS

Annals of internal medicine 20141001 7

<h4>Background</h4>Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure.<h4>Objective</h4>To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making.<h4>Design</h4>Analyses of repea ...[more]

PMID: 25285541

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Project description:BACKGROUND:Due to a low birth rate and an aging population, Japan faces an increase in the number of elderly people without children living in single households. These elderly without a spouse and/or children encounter a lack of caregivers because most sources of care for the elderly in Japan are not provided by private agencies but by family members. However, family caregivers not only help with daily living but are also key participants in treatment decision making. The effect of family absence on treatment decision making has not been elucidated, although more elderly people will not have family members to make surrogate decisions on their behalf. OBJECTIVE:The aim is to understand the influence of family absence on treatment decision making by physicians through a cross-sectional online survey with three hypothetical vignettes of patients. METHODS:We conducted a cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second was about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned to either of the two versions of the questionnaires-with family or without family-but methods were identical otherwise. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures. RESULTS:Among 1112 physicians, 454 (40.8%) completed the survey; there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR] 0.55, 95% CI 0.34-0.80; P=.002) and artificial ventilation (OR 0.51, 95% CI 0.35-0.75; P<.001) for a patient from vignette 1 without family. In vignette 2, fewer physicians were willing to perform artificial ventilation (OR 0.59, 95% CI 0.39-0.90; P=.02). In vignette 3, significantly fewer physicians showed willingness to perform wound treatment (OR 0.51, 95% CI 0.31-0.84; P=.007), surgery (OR 0.35, 95% CI 0.22-0.57; P<.001), blood transfusion (OR 0.45, 95% CI 0.31-0.66; P<.001), vasopressor (OR 0.49, 95% CI 0.34-0.72; P<.001), dialysis (OR 0.38, 95% CI 0.24-0.59; P<.001), artificial ventilation (OR 0.25, 95% CI 0.15-0.40; P<.001), and chest compression (OR 0.29, 95% CI 0.18-0.47; P<.001) for a patient without family. CONCLUSIONS:Elderly patients may have treatments withheld because of the absence of family, highlighting the potential importance of advance care planning in the era of an aging society with a declining birth rate.

Project description:ImportanceImprovements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist.ObjectiveTo identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States.Design, setting, and participantsSurvey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services.Main outcomes and measuresThe proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income.ResultsAmong the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (-6.7% [95% CI, -7.8 to -5.5]).Conclusions and relevanceDespite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.

Project description:BackgroundMobile health (mHealth) technology has the potential to support shared decision-making (SDM) and improve hypertension control. However, our understanding of the variations in individuals' involvement in SDM and mHealth usage across different racial and ethnic groups in the United States is still limited.ObjectiveThis study aimed to investigate the extent of involvement in SDM and the usage of mHealth technology in health-related activities among US adults with hypertension from diverse racial and ethnic backgrounds and to examine whether the mHealth usage differed by individuals' level of engagement in SDM.MethodsThis study used cross-sectional data from the 2017 to 2020 Health Information National Trends Survey, which was conducted on US adults with self-reported hypertension, and race and ethnicity data were included. The exposure of interest was race and ethnicity. The outcomes were SDM and mHealth usage. SDM was assessed using an item: "In the past 12 months, how often did your health professional: involve you in decisions about your healthcare as much as you wanted?" mHealth usage was defined as using a smartphone or tablet to engage in (1) making health decisions, (2) discussing health decisions with health providers, (3) tracking health progress, and (4) sharing health information. Weighted multivariable logistic regression models were used to examine the association between race and ethnicity and SDM or mHealth usage adjusted for covariates and stratified by the level of engagement in SDM.ResultsThis study included 4893 adults with hypertension, and the mean age was 61 (SD 13) years. The sample was 53% female, 61% (n=3006) non-Hispanic White, 19% (n=907) non-Hispanic Black or African American, 12% (n=605) Hispanic, 4% (n=193) non-Hispanic Asian, and 4% (n=182) non-Hispanic other. Compared to the non-Hispanic White adults, non-Hispanic Black adults were more likely to use mHealth to make health decisions (adjusted odds ratio [aOR] 1.70, 95% CI 1.23-2.34), share health information (aOR 1.46, 95% CI 1.02-2.08), and discuss health decisions with health providers (aOR 1.38, 95% CI 1.02-1.87). Significant associations were observed specifically among those who were always involved in SDM. Asian adults were less likely to be involved in SDM (aOR 0.51, 95% CI 0.26-0.99) and were more likely to use mHealth to track progress on a health-related goal (aOR 2.07, 95% CI 1.28-3.34) than non-Hispanic White adults. Hispanic adults were less likely to use mHealth to share health information (aOR 0.47, 95% CI 0.33-0.67) and discuss health decisions with health providers (aOR 0.65, 95% CI 0.46-0.94) compared to non-Hispanic White adults.ConclusionsThis study observed racial and ethnic disparities in SDM and mHealth usage among US adults with hypertension. These findings emphasize the significance of comprehending the involvement of SDM and the usage of mHealth technology within racially and ethnically diverse populations.

Dataset Information

Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.

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Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.

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