The Cost and Appropriateness of Radionuclide Exercise Stress Testing by Cardiologists and Non-cardiologists

It is generally accepted that patient with normal baseline electrocardiogram (ECG) should undergo exercise stress testing (EST) to establish the diagnosis and prognosis of coronary artery disease (CAD), unless standard EST exclusion criteri are present. Initial evaluation with radionuclide EST (REST) is an unproven approach that is approximately three times more expensive than EST alone. The appropriateness and financial ramifications of REST at an urban university hospital were evaluated during fourteen month period. Patients with clear indications for REST -- previously positive EST, prior myocardial infarction, or previous percutaneous transluminal coronary angioplasty -- were excluded. REST studies were performed for the diagnosis or management of CAD in 1902 patients, of whom 975 did not have chest pain. If the baseline ECG was normal and standard EST exclusion criteri (mitral valve prolapse, bundle-branch block, significant ST-segment deviation) were not present, REST was considered not indicated (N-IND). Non-cardiologists (N-CARD) were more likely than cardiologists (CARD) to order REST studies in patients without indications for isotopes. Assuming an excess charge of $1100 per patient, an unnecessary $1,082,400 was billed in this population, $409,200 of which was for patients who did not have chest pain. Assuming charge of $175 per patient, referral to cardiologist prior to REST would have saved $185,260 in this population. In conclusion, non-cardiologists are more likely to inappropriately order REST studies than are cardiologists, at significant excess cost. Although cardiologists also over utilize REST studies, referral to cardiologist prior to testing for CAD may be cost-effective.