Underuse and Overuse of Diagnostic Testing for Coronary Artery Disease in Patients Presenting with New-Onset Chest Pain

Published in: American Journal of Medicine, v. 106, no. 4, Apr. 1999, p. 391-398

Posted on RAND.org on December 31, 1998

by David Carlisle, Lucian L. Leape, Steven Bickel, Robert M. Bell, Caren Kamberg, Barbara Genovese, William J. French, Vidya S. Kaushik, Peter R. Mahrer, Myrvin H. Ellestad, Robert H. Brook, Martin F. Shapiro

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The purpose of this study was to determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and to determine whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influence the use of diagnostic tests. The authors identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire. Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 failed to receive necessary tests. Only 7 of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education and those without health insurance. In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse. The authors conclude that among patients with new-onset crest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

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