Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination

Abstract

IMPORTANCE Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk, asymptomatic patients, but the frequency and impact of such ECGs are unknown.OBJECTIVE To assess the frequency of ECGs following an annual health examination (AHE) with a primary care physician among patients with no known cardiac conditions or risk factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to compare downstream cardiac testing and clinical outcomes in low-risk patients who did and did not receive an ECG after their AHE. DESIGN, SETTING, AND PARTICIPANTSA population-based retrospective cohort study using administrative health care databases from Ontario, Canada, between 2010/2011 and 2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes of interest in this time frame. All patients 18 years or older who had no prior cardiac medical history or risk factors who received an AHE.EXPOSURES Receipt of an ECG within 30 days of an AHE. MAIN OUTCOMES AND MEASURESPrimary outcome was receipt of downstream cardiac testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization, and revascularization at 12 months. RESULTS A total of 3 629 859 adult patients had at least 1 AHE between fiscal years 2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE. The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among 679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to 94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were significantly more likely to receive additional cardiac tests, visits, or procedures than those who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs 0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations (0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts.CONCLUSIONS AND RELEVANCE Despite recommendations to the contrary, ECG testing after an AHE is relatively common, with significant variation among primary care physicians. Routine ECG testing seems to increase risk for a subsequent cardiology testing and consultation cascade, even though the overall cardiac event rate in both groups was very low.

Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: a retrospective cohort study

“…Client Agency Program Enrolment (CAPE) tables were cross-referenced with OHIP claims to identify patients rostered to primary care physicians, as well as groups of 3 or more physicians who submitted joint billing to the Ontario Ministry of Health and Long-Term Care (herein referred to as a practice). [12][13][14] The Discharge Abstract Database and National Ambulatory Care Reporting System contain inpatient hospitalization and emergency department visit records, respectively, which are both coded using the enhanced Canadian version of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10-CA), and the Canadian Classification of Health Interventions (CCI) coding systems.…”

“…12,15,16 These codes are representative of a PHE, as they describe screening and prevention services performed on patients without apparent medical problems on the basis of history or examination. 12,15,16 The K131 and K132 codes were introduced in January 2013 to provide a more flexible alternative to the annual health examination with the expressed intention of reducing low-value examinations and tests. 11,[16][17][18][19] We included 1 PHE per patient per quarter within the observation window; 20 however, OHIP guidelines limit reimbursement beyond 1 PHE per patient per 12 months per physician.…”

“…16 We excluded patients with incomplete demographic information and long-term care residents. 12 Additional exclusions were created by adapting the Canadian Association of Radiologists' standards and referral guidelines for chest radiography (specifically the cardiovascular, thoracic, cancer and trauma sections) to identify clinical scenarios in which the Canadian Association of Radiologists states that chest x-ray investigations are indicated (i.e., most likely to contribute to diagnosis or management). 4,6,17 We subsequently excluded patients with any of the following documented indications: signs/symptoms (e.g., dyspnea) or prior diagnosis of cardiac or respiratory disease; prior cardiac or thoracic surgery (e.g., aortic valve replacement); cancer diagnosis; or severe thoracic trauma or injury (e.g., pneumothorax).…”

Automated and Interpretable Patient ECG Profiles for Disease Detection, Tracking, and Discovery

“…The electrocardiogram (ECG) is the most commonly performed cardiovascular diagnostic procedure, with more than 100 million ECGs obtained annually in the United States (1), including use in 21% of annual health examinations (2) and 17% of emergency department visits (3). The ECG tracing is a direct reflection of underlying cardiac physiology, since its morphologic and temporal features are produced from cardiac electrical and structural variations.…”

Screening ECGs in low-risk patients are associated with increased risk of downstream cardiac testing

“…This population-based retrospective cohort study was performed using the administrative healthcare databases from Canada between 2010 and 2015 3. The primary exposure was receipt of an ECG within 30 days of an annual health examination (AHE).…”