Original Investigation |

Hospital Variation in the Use of Noninvasive Cardiac Imaging and Its Association With Downstream Testing, Interventions, and Outcomes

Kyan C. Safavi, BS1; Shu-Xia Li, PhD2,3; Kumar Dharmarajan, MD, MBA2,4; Arjun K. Venkatesh, MD, MBA5,6; Kelly M. Strait, MS2,3; Haiqun Lin, MD, PhD2,7; Timothy J. Lowe, PhD8; Reza Fazel, MD, MSc9; Brahmajee K. Nallamothu, MD, MPH10,11,12; Harlan M. Krumholz, MD, SM2,3,6,13
[+] Author Affiliations
1Yale University School of Medicine, New Haven, Connecticut
2Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
4Division of Cardiology, Columbia University Medical Center, New York, New York
5Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
6Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
7Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
8Premier Inc, Charlotte, North Carolina
9Division of Cardiology, Department of Medicine, Emory University School of Medicine and Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia
10Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
11Department of Internal Medicine, University of Michigan, Ann Arbor
12Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
13Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
JAMA Intern Med. 2014;174(4):546-553. doi:10.1001/jamainternmed.2013.14407.
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Importance  Current guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes.

Objective  To characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes.

Design, Setting, and Participants  Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease. We excluded patients with AMI.

Main Outcomes and Measures  At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures.

Results  We identified 549 078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8% (10.9%-27.7%); range, 0.2% to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2% vs Q4, 4.9%), and revascularization procedures (Q1, 0.5% vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6% vs Q4, 5.4%) and for angiograms (Q1, 41.2% vs Q4, 38.8%). P <.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P =.51). Approximately 23% of variation in imaging use was attributable to the behavior of individual hospitals.

Conclusions and Relevance  Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography.

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Figure 1.
Hospital Rates of Cardiac Imaging, Catheterization for Coronary Angiogram, and Revascularization

Each data point represents 1 hospital, and the trend line represents the regression line of imaging rate vs rank of imaging use rate.

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Figure 2.
Proportion of Cardiac Imaging Tests of Different Modality Types

Each bar represents 1 hospital. CT indicates computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography.

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