Implementation of a Computerized Order Entry Tool to Reduce the Inappropriate and Unnecessary Use of Cardiac Stress Tests With Imaging in Hospitalized Patients

Abstract

The rising use of imaging cardiac stress tests has led to potentially unnecessary testing. Interventions designed to reduce inappropriate stress testing have focused on the ambulatory setting. We developed a computerized order entry tool intended to reduce the use of imaging cardiac stress tests and improve appropriate use in hospitalized patients. The tool was evaluated using preimplementation and postimplementation cohorts at a single urban academic teaching hospital. All hospitalized patients referred for testing were included. The co-primary outcomes were the use of imaging stress tests as a percentage of all stress tests and the percentage of inappropriate tests, compared between the 2 cohorts. There were 478 patients in the precohort and 463 in the postcohort. The indication was chest pain in 66% and preoperative in 18% and was not significantly different between groups. The use of nonimaging stress tests increased from 4% in the pregroup to 15% in the postgroup (p<0.001). Among very low-risk chest pain patients, the use of nonimaging stress tests increased from 7% to 25% (p <0.001). Inappropriate testing did not change significantly between groups (12% vs 11%). Inappropriate tests were most often preoperative evaluations (83%). In conclusion, our computerized ordering tool significantly increased the use of nonimaging cardiac stress tests and reduced the use of imaging tests yet was not able to reduce inappropriate use. Our study highlights the differences in cardiac stress testing between hospitalized and ambulatory patients.