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The chapter When to Use Exercise Testing—Indications, Guidelines, and Appropriate Use Criteria (AUC) reviews and interprets the American College of Cardiology and American Heart Association guidelines and AUC. Exercise testing remains the cornerstone of the evaluation of coronary artery disease (CAD) in patients whose electrocardiogram is interpretable for ischemia and who are expected to be able to achieve ≥85% maximum predicted heart rate with exercise. If either is not the case, or if greater test sensitivity is clinically necessary, pharmacologic testing with myocardial perfusion imaging (MPI) or stress echocardiography is indicated. The Duke Activity Status Index (DASI) score can be used as a tool to determine to predict if a patient can perform the recommended ≥5 metabolic equivalents (METs) on an exercise test. The HEART score can be effectively used to determine low risk patients presenting to the emergency room with chest pain can be safely discharged for outpatient evaluation.
The chapter When to Use Exercise Testing—Indications, Guidelines, and Appropriate Use Criteria (AUC) reviews and interprets the American College of Cardiology and American Heart Association guidelines and AUC. Exercise testing remains the cornerstone of the evaluation of coronary artery disease (CAD) in patients whose electrocardiogram is interpretable for ischemia and who are expected to be able to achieve ≥85% maximum predicted heart rate with exercise. If either is not the case, or if greater test sensitivity is clinically necessary, pharmacologic testing with myocardial perfusion imaging (MPI) or stress echocardiography is indicated. The Duke Activity Status Index (DASI) score can be used as a tool to determine to predict if a patient can perform the recommended ≥5 metabolic equivalents (METs) on an exercise test. The HEART score can be effectively used to determine low risk patients presenting to the emergency room with chest pain can be safely discharged for outpatient evaluation.
Background Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. Methods A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. Results A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. Conclusions A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. Systematic review registration: PROSPERO: CRD42020208072.
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