FACILITY-LEVEL VARIATION IN CARDIAC STRESS TEST UTILIZATION AMONG PATIENTS WITH DIABETES MELLITUS: FINDINGS FROM THE VETERANS AFFAIRS NATIONAL DATABASE

Background. Preoperative anesthetic evaluations of patients before surgery traditionally involves assessment of a patient’s functional capacity to estimate perioperative risk of cardiovascular complications and need for further workup. This is typically done by inquiring about the patient’s physical activity, with the goal of providing an estimate of the metabolic equivalents (METs) that the patient can perform without signs of myocardial ischemia or cardiac failure. We sought to compare estimates of patients’ METs between preoperative assessment by medical history with quantified assessment of METs via the exercise cardiac stress test. Methods. A single-center retrospective chart review from 12/1/2005 to 5/31/2015 was performed on 492 patients who had preoperative evaluations with a cardiac stress test ordered by a perioperative anesthesiologist. Of those, a total of 170 charts were identified as having a preoperative evaluation note and an exercise cardiac stress test. The METs of the patient estimated by history and the METs quantified by the exercise cardiac stress test were compared using a Bland–Altman plot and Cohen’s kappa. Results. Exercise cardiac stress test quantified METs were on average 3.3 METS higher than the METs estimated by the preoperative evaluation history. Only 9% of patients had lower METs quantified by the cardiac stress test than by history. Conclusions. The METs of a patient estimated by preoperative history often underestimates the METs measured by exercise stress testing. This demonstrates that the preoperative assessments of patients’ METs are often conservative which errs on the side of patient safety as it lowers the threshold for deciding to order further cardiac stress testing for screening for ischemia or cardiac failure.

Download Full-text

Facility-Level Variations in Kidney Disease Care among Veterans with Diabetes and CKD

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.03830318 ◽

2018 ◽

Vol 13 (12) ◽

pp. 1842-1850 ◽

Cited By ~ 5

Author(s):

Sankar D. Navaneethan ◽

Julia M. Akeroyd ◽

David Ramsey ◽

Sarah T. Ahmed ◽

Shiva Raj Mishra ◽

...

Keyword(s):

Veterans Affairs ◽

Creatinine Ratio ◽

Angiotensin Receptor ◽

Urine Protein ◽

Urine Albumin ◽

Patients With Diabetes ◽

Facility Level ◽

Rate Ratios ◽

Core Measures ◽

Median Rate

Background and objectivesFacility-level variation has been reported among veterans receiving care for various diseases. We studied the frequency and facility-level variations of guideline-recommended practices in patients with diabetes and CKD.Design, setting, participants, & measurementsPatients with diabetes and concomitant CKD (eGFR 15–59 ml/min per 1.73 m2, measured twice, 90 days apart) receiving care in 130 facilities across the Veterans Affairs Health Care System were included (n=281,223). We studied the proportions of patients (facility-level) receiving recommended core measures and facility-level variations of these study outcomes using median rate ratios, adjusting for various patient and provider-level factors. Median rate ratio quantifies the degree to which care may vary for similar patients receiving care at two randomly chosen facilities, with <1 being no variation and >1.2 as substantial variation between the facilities. Study outcomes included measurement of urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio and blood hemoglobin concentration, prescription of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, BP<140/90 mm Hg, and referral to a Veterans Affairs nephrologist (only for those with eGFR<30 ml/min per 1.73 m2).ResultsAmong those with eGFR 30–59 ml/min per 1.73 m2, proportion of patients receiving recommended core measures (median and interquartile range across facilities) were 37% (22%–47%) for urine albumin-to-creatinine ratio/urine protein-to-creatinine ratio, 74% (72%–79%) for hemoglobin measurement, 66% (62%–69%) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription, 85% (74%–87%) for statin prescription, 47% (42%–53%) for achieving BP<140/90 mm Hg, and 13% (7%–16%) for meeting all outcome measures. Adjusted median rate ratios (95% confidence intervals) were 5.2 (4.1 to 6.4), 2.4 (2.1 to 2.6), 1.3 (1.2 to 1.3), 1.2 (1.2 to 1.3), 1.4 (1.3 to 1.4), and 4.1 (3.3 to 5.0), respectively. Median rate ratios were qualitatively similar in an analysis restricted to those with eGFR 15–29 ml/min per 1.73 m2.ConclusionsAmong patients with diabetes and CKD, at facility-level, ordering of laboratory tests, and scheduling of nephrology referrals in eligible patients remains suboptimal, with substantial variations across facilities.

Download Full-text

Assessing post-cardiac stress test heart rate recovery and systolic blood pressure recovery in patients suffering from vasovagal syncope

Electronic Journal of General Medicine ◽

10.29333/ejgm/93476 ◽

2019 ◽

Vol 16 (2) ◽

pp. em118

Author(s):

Mehdi Moradi ◽

Maryam Farhadian ◽

Mehdi Kazemi

Keyword(s):

Blood Pressure ◽

Heart Rate ◽

Systolic Blood Pressure ◽

Heart Rate Recovery ◽

Vasovagal Syncope ◽

Stress Test ◽

Pressure Recovery ◽

Cardiac Stress ◽

Cardiac Stress Test

Download Full-text

Challenge of identifying patients with diabetes mellitus who are at low risk for coronary events by use of cardiac stress imaging

American Heart Journal ◽

10.1016/j.ahj.2003.12.012 ◽

2004 ◽

Vol 147 (4) ◽

pp. 561-563 ◽

Cited By ~ 22

Author(s):

Masoor Kamalesh ◽

Harvey Feigenbaum ◽

Stephen Sawada

Keyword(s):

Diabetes Mellitus ◽

Low Risk ◽

Stress Imaging ◽

Cardiac Stress ◽

Patients With Diabetes ◽

Coronary Events

Download Full-text

Low Cost Magnetic Resonance Imaging-Compatible Stepper Exercise Device for Use in Cardiac Stress Tests

Journal of Medical Devices ◽

10.1115/1.4027343 ◽

2014 ◽

Vol 8 (4) ◽

Cited By ~ 4

Author(s):

Omid Forouzan ◽

Evan Flink ◽

Jared Warczytowa ◽

Nick Thate ◽

Andrew Hanske ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Low Cost ◽

Stress Test ◽

Exercise Stress ◽

Resonance Imaging ◽

Pharmacological Stress ◽

Cardiac Stress ◽

Adjustable Weight ◽

Cardiac Stress Test

Cardiovascular disease is the leading cause of death worldwide. Many cardiovascular diseases are better diagnosed during a cardiac stress test. Current approaches include either exercise or pharmacological stress echocardiography and pharmacological stress magnetic resonance imaging (MRI). MRI is the most accurate noninvasive method of assessing cardiac function. Currently there are very few exercise devices that allow collection of cardiovascular MRI data during exercise. We developed a low-cost exercise device that utilizes adjustable weight resistance and is compatible with magnetic resonance (MR) imaging. It is equipped with electronics that measure power output. Our device allows subjects to exercise with a leg-stepping motion while their torso is in the MR imager. The device is easy to mount on the MRI table and can be adjusted for different body sizes. Pilot tests were conducted with 5 healthy subjects (3 male and 2 female, 29.2 ± 3.9 yr old) showing significant exercise-induced changes in heart rate (+42%), cardiac output (+40%) and mean pulmonary artery (PA) flow (+%49) post exercise. These data demonstrate that our MR compatible stepper exercise device successfully generated a hemodynamically stressed state while allowing for high quality imaging. The adjustable weight resistance allows exercise stress testing of subjects with variable exercise capacities. This low-cost device has the potential to be used in a variety of pathologies that require a cardiac stress test for diagnosis and assessment of disease progression.

Download Full-text