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Variation in Routine Electrocardiogram Use in Academic Primary Care Practice
Randall S. Stafford, MD, PhD;
Bismruta Misra, MPH
Arch Intern Med. 2001;161:2351-2355.
Background Lack of practical consensus regarding routine electrocardiogram (ECG)
ordering in primary care led us to hypothesize that nonclinical variations
in ordering would exist among primary care providers.
Methods We used 2 computerized billing systems to measure ECG ordering at visits
to providers in 10 internal medicine group practices affiliated with a large,
urban teaching hospital from October 1, 1996, to September 30, 1997. To focus
on screening or routine ECGs, patients with known cardiac disease or suggestive
symptoms were excluded, as were providers with fewer than 200 annual patient
visits. Included were 69 921 patients making 190 238 visits to 125
primary care providers. Adjusted rates of ECG ordering accounted for patient
age, sex, and 5 key diagnoses. Logistic regression evaluated additional predictors
of ECG ordering.
Results Electrocardiograms were ordered in 4.4% of visits to patients without
reported cardiac disease. Among the 10 group practices, ECG ordering varied
from 0.5% to 9.6% of visits (adjusted rates, 0.8%-8.6%). Variations between
individual providers were even more dramatic: adjusted rates ranged from 0.0%
to 24% of visits, with an interquartile range of 1.4% to 4.7% and a coefficient
of variation of 88%. Significant predictors of ECG use were older patient
age, male sex, and the presence of clinical comorbidities. Additional nonclinical
predictors included Medicare as a payment source, older male providers, and
providers who billed for ECG interpretation.
Conclusions Variations in ECG ordering are not explained by patient characteristics.
The tremendous nonclinical variations in ECG test ordering suggest a need
for greater consensus about use of screening ECGs in primary care.
From the Primary Care Operations Improvement Team and Institute for
Health Policy, Massachusetts General Hospital, Boston (Dr Stafford and Ms
Misra); and Howard University College of Medicine, Washington, DC (Ms Misra).
Dr Stafford is now with the Stanford Center for Research in Disease Prevention,
Palo Alto, Calif.
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