PATIENT BELIEFS AND PREFERENCES DO NOT EXPLAIN VARIATION IN SUBSEQUENT TESTING AFTER INITIAL EVALUATION FOR ISCHEMIC HEART DISEASE

Purpose: More than 4 million patients in the United States are newly evaluated each year for ischemic heart disease (IHD), and both policymakers and researchers have raised concerns about high variability in patterns of subsequent medical management and referral to follow-up cardiovascular tests and procedures, with reports of both under-treatment and over-treatment. Little is known about how patients’ beliefs and preferences influence subsequent clinical decisions, but a better understanding of this relationship is needed to effectively improve medical management and reduce unnecessary tests and procedures.  

Method: We surveyed 280 randomly selected patients without prior diagnosis of IHD who were newly evaluated with stress echocardiography, stress myocardial perfusion imaging (MPI), or cardiac computed tomography angiography (CCTA) between November 1, 2013 and February 28, 2015 within Geisinger Health System. We assessed how important patients felt their initial test was to their health, whether they believed their initial test result was abnormal, and how likely they were to complete any recommended follow-up. Using electronic health records, we constructed logistic regression models of follow-up testing and procedures within 90 days while adjusting for anginal symptoms, initial test results, and other clinical and sociodemographic characteristics. Analyses accounted for survey design and nonresponse.

Result: Of 280 patients (mean age=59 years), 46% were men, 16% had diabetes, and 36% reported experiencing angina. The initial stress test or CCTA was abnormal in 8% and subsequent tests or procedures were performed on 11% (6% after normal test, 64% after abnormal test). Most patients felt their initial test was important (70%), had an accurate understanding of their test result (80%), and had strong preferences for completing recommended follow-up (64%). While cardiac risk factors and a test abnormality were associated with subsequent testing, patients’ beliefs about test importance (OR 0.9 [95% CI, 0.4–1.7]), understanding of initial results (OR 1.2 [95% CI, 0.6–2.7]), and preferences for follow-up (OR 0.9 [95% CI, 0.5–1.7]) were not.

Conclusion: Among patients with suspected ischemic heart disease, variation in subsequent testing and procedures cannot be explained by patient beliefs or preferences. Variation that leads to over-treatment or under-treatment may be better addressed by focusing on physician factors.