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Pamela S Douglas - One of the best experts on this subject based on the ideXlab platform.
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appropriateness of Cardiac Stress Test use among primary care physicians and cardiologists in the united states
International Journal of Cardiology, 2016Co-Authors: Joseph A Ladapo, Saul Blecker, Pamela S DouglasAbstract:Age, yrs 18–64 13 1.00 ≥65 14 0.97 0.56 to 1.68 0.90 Gender Male 12 1.00 Female 15 1.31 0.85 to 2.02 0.22 Race/ethnicity White 12 1.00 Black 21 1.65 0.88 to 3.11 0.12 Other 20 1.58 0.49 to 5.16 0.44 Private insurance No 15 1.00 Yes 12 0.63 0.37 to 1.09 0.10 Region Northeast 7 1.00 Midwest 12 1.39 0.57 to 3.42 0.47 South 15 2.00 0.95 to 4.24 0.07 West 16 1.94 0.83 to 4.50 0.12 Physician specialty Cardiology 9 1.00 Primary care 21 3.08 1.88 to 5.05 b0.001 Other 22 2.65 1.17 to 6.04 0.02 Smoker No 11 1.00 Yes 10 0.87 0.48 to 1.60 0.66 Unknown 19 1.59 0.93 to 2.72 0.09 Visit diagnosis Hypertension 11 0.62 0.41 to 0.93 0.02 Dyslipidemia 13 1.14 0.75 to 1.73 0.54
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physician decision making and trends in the use of Cardiac Stress Testing in the united states an analysis of repeated cross sectional data
Annals of Internal Medicine, 2014Co-Authors: Joseph A Ladapo, Saul Blecker, Pamela S DouglasAbstract:BACKGROUND: Cardiac Stress Testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure. OBJECTIVE: To determine whether U.S. trends in Cardiac Stress Test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making. DESIGN: Analyses of repeated cross-sectional data. SETTING: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010). PATIENTS: Adults without coronary heart disease. MEASUREMENTS: Cardiac Stress Test referrals and inappropriate use. RESULTS: Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a Cardiac Stress Test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent Testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac Stress Tests with imaging comprised a growing portion of all Tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a Cardiac Stress Test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]). LIMITATION: Cross-sectional design with limited clinical data. CONCLUSION: National growth in Cardiac Stress Test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about Cardiac Stress Test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.
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physician decision making and trends in the use of Cardiac Stress Testing in the united states an analysis of repeated cross sectional data
Annals of Internal Medicine, 2014Co-Authors: Joseph A Ladapo, Saul Blecker, Pamela S DouglasAbstract:BACKGROUND Cardiac Stress Testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure. OBJECTIVE To determine whether U.S. trends in Cardiac Stress Test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making. DESIGN Analyses of repeated cross-sectional data. SETTING National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010). PATIENTS Adults without coronary heart disease. MEASUREMENTS Cardiac Stress Test referrals and inappropriate use. RESULTS Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a Cardiac Stress Test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent Testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac Stress Tests with imaging comprised a growing portion of all Tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a Cardiac Stress Test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]). LIMITATION Cross-sectional design with limited clinical data. CONCLUSION National growth in Cardiac Stress Test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about Cardiac Stress Test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.
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patterns of Cardiac Stress Testing after revascularization in community practice
Journal of the American College of Cardiology, 2010Co-Authors: Bimal R Shah, Patricia A Cowper, Sean M Obrien, Neil Jensen, Matthew Drawz, Manesh R Patel, Pamela S Douglas, Eric D PetersonAbstract:Objectives The purpose of this study was to determine the pattern of Cardiac Stress Testing after coronary revascularization in community practice. Background The American College of Cardiology Foundation appropriate use criteria provide guidance for the use of Cardiac Stress imaging after coronary revascularization. However, little is known regarding the use of routine Cardiac Stress Testing in coronary artery bypass grafting or percutaneous coronary intervention patients as well as their downstream use of invasive procedures after noninvasive Testing in community practice. Methods Use and timing of Stress Testing more than 90 days after revascularization in patients 18 to 64 years of age were determined from a national health insurance claims database from July 1, 2004, through June 30, 2007. Subsequent rates of angiography and repeat revascularization after Stress Testing also were examined. Results Of 28,177 patients undergoing revascularization (21,046 percutaneous coronary intervention procedures and 7,131 coronary artery bypass grafting procedures), 59% had at least 1 Cardiac Stress Test within 24 months. Sixty-one percent of patients with percutaneous coronary intervention and 51% of patients with coronary artery bypass grafting had undergone Testing by 24 months. Nuclear imaging was the predominant Testing method. The incidence of Testing was found to increase at both 6 months and 12 months after revascularization, suggesting an association with elective follow-up office visits. Furthermore, Testing varied according to geographic location. Of those Tested, only 11% underwent subsequent Cardiac catheterization and only 5% underwent repeat revascularization. Conclusions Although there is limited consensus as to the appropriate role of elective Stress Testing after coronary revascularization, more than one half of all patients in community practice had at least 1 Stress Test within 24 months of revascularization. Yield on such Testing was low: only 5% of patients Tested ultimately required repeat revascularization. These findings support the need to define better the role of Stress Testing after recent revascularization.
Todd C Kerwin - One of the best experts on this subject based on the ideXlab platform.
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inadequate blood pressure control in hypertensive patients referred for Cardiac Stress Test
Journal of Clinical Hypertension, 2015Co-Authors: Tarek M Mousa, Oluwaseun A Akinseye, Todd C KerwinAbstract:The current study examined the degree of blood pressure (BP) control and incidence of myocardial ischemia in hypertensive patients (n=2039) referred for Cardiac Stress Test. Patients were categorized into well-controlled ( 160/100 mm Hg) groups according to their resting BP. The mean age[±standard error of the mean] of the patients was 68±13 years, and 885 (43.4%) were men. The prevalence of well-controlled hypertension (HTN) was 47.2%, poorly controlled HTN was 29.5%, and very poorly controlled HTN was 23.3%. Evidence of ischemia was seen in 19.8% and 19.3% of the well-controlled and poorly controlled groups, respectively. The very poorly controlled group had the lowest incidence of ischemia (14.3%) (P<.05) compared with the other two groups. Symptoms that mimic ischemic heart disease in hypertensive patients may be partly explained by poorly controlled BP. Quality of care might be improved by optimally controlling BP in patients with angina symptoms prior to ordering diagnostic Testing associated with radiation exposure and cost.
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abstract p155 inadequate blood pressure control in hypertensive patients referred for Cardiac Stress Test
Hypertension, 2015Co-Authors: Tarek M Mousa, Oluwaseun A Akinseye, Todd C KerwinAbstract:Introduction: Hypertension (HTN) is a powerful risk factor for fatal and nonfatal cardiovascular events. Achieving adequate blood pressure (BP) control can reduce morbidity and mortality from cardiovascular diseases.The current study examined the degree of BP control and incidence of myocardial ischemia in hypertensive patients referred for Cardiac Stress Test. Methods: We retrospectively analyzed 2,039 consecutive patients with the diagnosis of HTN referred to New York Hospital Medical Center of Queens/Weill Cornell Medical College nuclear cardiology laboratory for Stress Testing from January 2007 through July 2010. Patients were categorized into well-controlled ( 160/100 mmHg) groups according to their resting BP measured by an IntelliVue MP70 (Royal Philips Electronics, the Netherlands) non-invasive oscillometric BP monitor. The incidence of ischemia was defined as the presence of at least one reversible perfusion defect on Stress/rest single photon emission computed tomography scan Results: Mean age [±SEM] = 68 ± 13 years, 885 (43.4%) were males. Prevalence of well-controlled HTN was 47.2%, poorly-controlled HTN, 29.5% and very poorly-controlled HTN, 23.3%. Evidence of ischemia was seen in 19.8% and 19.3% of the well-controlled and poorly-controlled group respectively. The very poorly-controlled group had the lowest incidence of ischemia (14.3%) (p < 0.05) compared to the other two groups. Conclusions: Symptoms mimicking ischemic heart disease in hypertensive patients may be partly explained by poorly controlled BP. Quality of care might be improved by optimally controlling BP in patient with angina symptoms prior to ordering diagnostic Testing associated with radiation exposure and cost
Dhruv Mahtta - One of the best experts on this subject based on the ideXlab platform.
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facility level variation in Cardiac Stress Test use among patients with diabetes findings from the veterans affairs national database
Diabetes Care, 2020Co-Authors: Nishant R. Shah, Sarah T. Ahmed, Julia M. Akeroyd, Dhruv Mahtta, Khurram NasirAbstract:Cardiac Stress Testing in patients with diabetes mellitus (DM) is a topic of much debate (1,2). The clinical heterogeneity and varied interpretation of atypical symptoms in this population may lead to significant variation in Cardiac Stress Testing with downstream implications in health care expenditure. We evaluated facility-level variation in Cardiac Stress Test use among patients with DM across the Veterans Affairs (VA) health care system. We identified patients with DM aged ≥18 years with a primary care clinic visit during VA fiscal year 2014 at one of the 130 VA facilities and associated clinics. Patient demographics and medical history were identified using clinical data sources and ICD-9-CM codes. We calculated diagnostic cost group relative risk score (DCG-RRS), a validated surrogate for overall illness burden. Facility-level Cardiac Stress Test use was defined as the number of Stress Tests performed per facility per 100 patients with DM in the preceding 365 days. Stress Testing modalities evaluated included exercise treadmill Test, Stress echocardiography, and SPECT/PET MPI (myocardial perfusion imaging [single photon emission computed tomography or positron emission tomography]). Facilities with <10 studies/year were excluded. Median risk ratio (MRR), a well-established measure of facility-level variation (3), was derived by constructing multivariable hierarchical modified regression models adjusted for patient clustering and modeled patient characteristics as filter effects within each facility and individual facilities as a random effect (4). Unadjusted and adjusted MRRs (adjustment for patient, provider, and facility-level variables) were calculated for overall Stress Testing and individual Stress modalities. MRR represents the likelihood of two …
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facility level variation in Cardiac Stress Test utilization among patients with diabetes mellitus findings from the veterans affairs national database
Journal of the American College of Cardiology, 2020Co-Authors: Dhruv Mahtta, Nishant R. Shah, Sarah T. Ahmed, Julia M. Akeroyd, Stephen W. Waldo, Khurram Nasir, Ihab Hamzeh, Islam Y Elgendy, Mouaz H AlmallahAbstract:Cardiac Stress Testing in diabetics has been a topic of much debate. We assessed facility-level variation in Stress Test utilization among patients with diabetes mellitus (DM) with hopes of identifying mechanisms to curtail inefficiencies and improve care. We used 2013–2014 nationwide VA
Mouaz H Almallah - One of the best experts on this subject based on the ideXlab platform.
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facility level variation in Cardiac Stress Test utilization among patients with diabetes mellitus findings from the veterans affairs national database
Journal of the American College of Cardiology, 2020Co-Authors: Dhruv Mahtta, Nishant R. Shah, Sarah T. Ahmed, Julia M. Akeroyd, Stephen W. Waldo, Khurram Nasir, Ihab Hamzeh, Islam Y Elgendy, Mouaz H AlmallahAbstract:Cardiac Stress Testing in diabetics has been a topic of much debate. We assessed facility-level variation in Stress Test utilization among patients with diabetes mellitus (DM) with hopes of identifying mechanisms to curtail inefficiencies and improve care. We used 2013–2014 nationwide VA
Michael W. Wiederman - One of the best experts on this subject based on the ideXlab platform.
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The relationship between borderline personality symptoms and body mass index in a consecutive sample of Cardiac Stress Test patients.
Eating and weight disorders : EWD, 2012Co-Authors: Randy A. Sansone, Nathaniel Dittoe, H. S. Hahn, Michael W. WiedermanAbstract:Borderline personality disorder (BPD) is characterized by inherent difficulties with self-regulation. While a number of studies have examined the relationship between BPD and body mass index (BMI)/overweight/obesity, findings have been mixed. In this cross-sectional study of a consecutive sample of 238 participants presenting for Cardiac Stress Testing, we investigated the relationship between borderline personality symptoms, according to two self-report measures, and BMI. Compared to participants who were negative on both measures of borderline personality symptoms, participants who were positive on either measure of borderline personality symptoms demonstrated no differences in current BMI or highest BMI in adulthood. These results in a unique study population mirror the findings of other studies in medical and community populations.
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The relationship between childhood trauma and borderline personality symptomatology in a consecutive sample of Cardiac Stress Test patients.
International journal of psychiatry in clinical practice, 2011Co-Authors: Randy A. Sansone, Nathaniel Dittoe, Harvey S. Hahn, Michael W. WiedermanAbstract:AbstractObjective. In this study, we examined relationships between five types of childhood trauma and two measures of borderline personality symptomatology in a non-psychiatric clinical population in order to assess a potential association between these variables in a non-psychiatric-treatment-seeking population. Method. Using a cross-sectional sample and a survey approach in 250 consecutive patients presenting for Cardiac Stress Testing, we explored self-reported histories of five types of childhood trauma (i.e. witnessing violence, physical neglect, emotional abuse, physical abuse, sexual abuse), several aspects of past mental healthcare, and borderline personality symptomatology using two self-report measures (the borderline personality disorder scale of the Personality Diagnostic Questionnaire-4 and the Self-Harm Inventory). Results. All relationships between the individual forms of trauma and total number of childhood traumas, and measures of borderline personality symptomatology, attained statistic...
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The prevalence of borderline personality disorder in a consecutive sample of Cardiac Stress Test patients.
The primary care companion for CNS disorders, 2011Co-Authors: Randy A. Sansone, Nathaniel Dittoe, Harvey S. Hahn, Michael W. WiedermanAbstract:To the Editor: There are a number of empirical studies that have examined prevalence rates of borderline personality disorder (BPD) in various medical syndromes. Elevated rates of BPD have been associated with somatoform and fictitious disorders1; somatic preoccupation2; medically self-harming behavior among both psychiatric inpatients3 and internal medicine outpatients4; interference with wound healing5; chronic pain sydnromes6; various other “syndrome-like” conditions (eg, chronic fatigue, fibromyalgia) as well as osteoarthritis, diabetes, and hypertension7; and medical disorders such as hypertension, hepatic disease, cardiovascular disease, and “any assessed medical condition.”8 However, several studies report rates of BPD in specific medical populations that are comparable to rates for the disorder encountered in the general population (eg, various pain syndromes,9,10 pain medication use,11 and various psychophysiologic disorders10). Indeed, the factors that influence associations between BPD and various medical phenomena are poorly understood. In this study, we examined the prevalence of BPD in a consecutive sample of Cardiac Stress Test patients to determine if Cardiac symptoms might be overrepresented among individuals with BPD. Method. Participants in this study were consecutive male or female patients aged 18 years or older undergoing Cardiac Stress Testing in a community hospital from June 6, 2010, to September 3, 2010. The sample was drawn from a middle-to-high socioeconomic suburb of a medium-sized midwestern city. Exclusion criteria were medical (eg, pain), psychiatric (eg, psychosis), or intellectual disturbances that would preclude the successful completion of a survey booklet. Two recruiters approached 302 candidates and enrolled 251 participants, for a response rate of 83.1%. Among the 251 participants, 118 were male and 133 female; age ranged from 20 to 91 years (mean = 58.00, SD = 13.85). The large majority were white (93.2%), followed by black (3.2%), Native American (1.6%), other ethnicity (1.2%), and Asian (0.4%). One respondent (0.4%) did not indicate ethnicity. With regard to education attainment, 19 (7.6%) had not finished high school, 73 (29.1%) had only a high school diploma, 74 (29.5%) had attended college but had no degree, 12 (4.8%) had earned a 2-year degree, 31 (12.4%) had earned a 4-year degree, and 39 (15.5%) had earned a graduate degree. Three respondents (1.2%) did not indicate their educational attainment. Following an explanation of the research project and the signing of consent forms, each participant completed a survey booklet that explored demographic information and contained 2 measures of BPD: (1) the BPD scale of the Personality Diagnostic Questionnaire-412 (PDQ-4) and (2) the Self-Harm Inventory (SHI).13 Survey booklets were then placed in sealed envelopes and stored, pending analysis. This project was approved by the institutional review boards of the participating hospital and the local university. Results. Using the traditional cutoff scores of 5 for each meaure, 15 individuals (6.0%) scored positively on the PDQ-4 and 12 (4.8%) scored positively on the SHI; 5 (2.0%) scored positively on both measures, whereas 22 (8.8%) scored positively on either one measure or the other. In comparing the demographic profiles between those respondents who scored positively on either measure versus those respondents who scored negatively on both measures, there were no differences with regard to sex (χ2 = 0.58, P < .51). Similarly, there were no between-group differences in comparing white respondents to respondents of any other race (χ2 = 2.09, P < .15) or respondents with no more than a high school education to those with at least some college education (χ2 = 0.01, P < .95). However, those who scored positively on either measure of BPD were younger (mean = 48.77 years, SD = 13.01) on average compared to those who scored negatively on both measures of BPD (mean = 58.91 years, SD = 13.66) (F1,248 = 11.14, P < .001). How do the preceding rates in this study compare with general community rates? While the DSM-IV-TR states that the prevalence of BPD in the general population is 2%, Grant et al,14 in the National Epidemiologic Survey on Alcohol and Related Conditions, found a prevalence rate for BPD of 5.9%. With the exception of the percentage of respondents who were positive on either one measure or the other (but not both), all remaining prevalence findings in this study are at or below the recent US community prevalence rate determined by Grant et al.14 In other words, we did not find elevated rates of BPD in this sample of patients undergoing Cardiac Stress Testing. A number of factors may explain these findings. First, individuals with BPD may gravitate away from disorders with definitive diagnoses (ie, Cardiac disease). Second, the higher socioeconomic level of the study's geographic area may have precluded lower-functioning individuals with BPD. Third, referring clinicians and participating cardiologists may have deferred for Cardiac Stress Testing those individuals with somatic features. Fourth, BPD measures with symptom criteria that are based on studies in younger populations (eg, self-cutting) may have underdetected symptoms in an older population. This is the first study to examine the prevalence of BPD in a population undergoing Cardiac Stress Testing. Findings are potentially limited by the use of self-report measures for BPD. However, self-report measures run the risk of being overinclusive, and the prevalence rates for BPD in this study generally did not exceed general population norms. In addition, we used 2 measures of BPD, obtained a consecutive sample, and captured a reasonable sample size of patients. According to these findings, BPD is not overrepresented among patients who are referred for Cardiac Stress Testing.
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The prevalence of self-harm behaviors in a consecutive sample of Cardiac Stress Test patients.
International journal of psychiatry in medicine, 2011Co-Authors: Randy A. Sansone, Nathaniel Dittoe, Harvey S. Hahn, Michael W. WiedermanAbstract:While self-harm behavior has been studied in various psychiatric populations, particularly the behaviors of suicide attempts and completions, little empirical data exists on the lifetime prevalence of various self-harm behaviors in non-psychiatric populations. In the present study, using a cross-sectional approach and a self-report survey methodology, we examined the lifetime prevalence of 22 self-harm behaviors in a consecutive sample of 250 patients undergoing Cardiac Stress Testing. Results indicated that abuse alcohol was most common (17.2%) followed by promiscuity (10.4%); 6% reported a previous suicide atatempt. Findings indicate areas of clinician inquiry for self-harm behaviors in non-psychiatric patients.