Department of Medicine, University of Toronto, Toronto, Ontario, Canada
ICES, Toronto, Ontario, Canada.
BMJ Open. 2022 Mar 10;12(3):e059199. doi: 10.1136/bmjopen-2021-059199.
To identify patient, physician and geographic level factors that are associated with variation in initial stress testing strategy in patients evaluated for chest pain.
Retrospective cohort study.
Population-based study of patients undergoing evaluation for chest pain in Ontario, Canada between 1 January 2011 and 31 March 2018.
103 368 patients who underwent stress testing (graded exercise stress testing (GXT), stress echocardiography (stress echo) or myocardial perfusion imaging (MPI)) following evaluation for chest pain.
To identify the patient, physician and geographic level factors associated with variation in initial test selection, we fit two separate 2-level hierarchical multinomial logistic regression models for which the outcome was initial stress testing strategy (GXT, MPI or stress echo).
There was significant variability in the initial type of stress test performed, with approximately 50% receiving a GXT compared with approximately 36% who received MPI and 14% who received a stress echo. Physician-level factors were key drivers of this variation, accounting for up to 59.0% of the variation in initial testing. Physicians who graduated medical school >30 years ago were approximately 45% more likely to order an initial stress echo (OR 1.45, 95% CI 1.17 to 1.80) than a GXT. Cardiovascular disease specialists were approximately sevenfold more likely to order an initial MPI (OR 7.35, 95% CI 5.38 to 10.03) than a GXT. Patients aged >70 years were approximately fivefold more likely to receive an MPI (OR 4.74, 95% CI 4.42 to 5.08) and approximately 26% more likely to receive a stress echo (OR 1.26, 95% CI 1.15 to 1.38) than a GXT.
We report significant variability in initial stress testing strategy in Ontario. Much of that variability was driven by physician-level factors that could potentially be addressed through educational campaigns geared at reducing this variability and improving guideline adherence.
确定与胸痛患者初始应激测试策略差异相关的患者、医生和地理水平因素。
回顾性队列研究。
在加拿大安大略省，对 2011 年 1 月 1 日至 2018 年 3 月 31 日期间接受胸痛评估的患者进行人群基础的应激测试研究。
103368 名接受应激测试（分级运动应激测试（GXT）、应激超声心动图（stress echo）或心肌灌注成像（MPI））的患者。
为了确定与初始测试选择差异相关的患者、医生和地理水平因素，我们使用两个单独的 2 级分层多项逻辑回归模型来确定初始应激测试策略（GXT、MPI 或 stress echo）。
初始应激测试类型存在显著差异，约 50%的患者接受 GXT，约 36%的患者接受 MPI，14%的患者接受 stress echo。医生水平因素是这种差异的主要驱动因素，占初始测试差异的 59.0%。毕业于 30 年前的医学院的医生，其初始选择 stress echo 的可能性大约高 45%（OR 1.45，95%CI 1.17 至 1.80），而不是 GXT。心血管疾病专家初始选择 MPI 的可能性大约是 GXT 的 7 倍（OR 7.35，95%CI 5.38 至 10.03）。年龄>70 岁的患者接受 MPI 的可能性大约是 GXT 的 5 倍（OR 4.74，95%CI 4.42 至 5.08），接受 stress echo 的可能性大约是 GXT 的 26%（OR 1.26，95%CI 1.15 至 1.38）。
我们报告了安大略省初始应激测试策略的显著差异。其中大部分差异是由医生水平因素驱动的，这可以通过有针对性的教育活动来解决，以减少这种差异并提高指南的依从性。
