Patterns of Use and Clinical Utility of Exercise Thallium-201 Single Photon Emission-Computed Tomography in a Community Hospital

McClellan, Joseph R.; Dugan, Thomas M.; Heller, Gary V.

doi:10.1159/000177076

Cited by 1 publication

(2 citation statements)

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“…11–12,14,24–41 In this analysis, the referral rates after normal and abnormal exercise tests were 4.1% (95% CI, 2.8% to 5.3%) and 43.7% (36.5% to 50.9%), respectively, with odds ratio for referral after an abnormal test of 14.3 (9.8 to 20.7). After adjusting for referral, the sensitivity of exercise ECHO and MPI fell to 34% (95% CI, 26% to 41%) and 38% (95% CI, 31% to 44%) and the specificity rose to 99% (95% CI, 99% to 100%) and 99% (95% CI, 99% to 100%), respectively.…”

Section: Resultsmentioning

confidence: 72%

“…Of these 107 studies, 17 reported referral patterns after normal or abnormal exercise tests and were included in our analysis. 11–12,14,24–41 The characteristics of these studies and their 49 006 participants are shown in Table 1. The mean age was 60.7 years, 39.6% were women, 0.8% had a prior history of myocardial infarction (reported in 13 studies), and 0.1% had a prior history of revascularization (reported in 14 studies).…”

Section: Resultsmentioning

confidence: 99%

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Clinical Implications of Referral Bias in the Diagnostic Performance of Exercise Testing for Coronary Artery Disease

Ladapo

Blecker

Elashoff

et al. 2013

JAHA

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BackgroundExercise testing with echocardiography or myocardial perfusion imaging is widely used to risk‐stratify patients with suspected coronary artery disease. However, reports of diagnostic performance rarely adjust for referral bias, and this practice may adversely influence patient care. Therefore, we evaluated the potential impact of referral bias on diagnostic effectiveness and clinical decision‐making.Methods and ResultsSearching PubMed and EMBASE (1990–2012), 2 investigators independently evaluated eligibility and abstracted data on study characteristics and referral patterns. Diagnostic performance reported in 4 previously published meta‐analyses of exercise echocardiography and myocardial perfusion imaging was adjusted using pooled referral rates and Bayesian methods. Twenty‐one studies reported referral patterns in 49 006 patients (mean age 60.7 years, 39.6% women, and 0.8% prior history of myocardial infarction). Catheterization referral rates after normal and abnormal exercise tests were 4.0% (95% CI, 2.9% to 5.0%) and 42.5% (36.2% to 48.9%), respectively, with odds ratio for referral after an abnormal test of 14.6 (10.7 to 19.9). After adjustment for referral, exercise echocardiography sensitivity fell from 84% (80% to 89%) to 34% (27% to 41%), and specificity rose from 77% (69% to 86%) to 99% (99% to 100%). Similarly, exercise myocardial perfusion imaging sensitivity fell from 85% (81% to 88%) to 38% (31% to 44%), and specificity rose from 69% (61% to 78%) to 99% (99% to 100%). Summary receiver operating curve analysis demonstrated only modest changes in overall discriminatory power but adjusting for referral increased positive‐predictive value and reduced negative‐predictive value.ConclusionsExercise echocardiography and myocardial perfusion imaging are considerably less sensitive and more specific for coronary artery disease after adjustment for referral. Given these findings, future work should assess the comparative ability of these and other tests to rule‐in versus rule‐out coronary artery disease.

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