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Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease.

Publication ,  Journal Article
Ladapo, JA; Blecker, S; Elashoff, MR; Federspiel, JJ; Vieira, DL; Sharma, G; Monane, M; Rosenberg, S; Phelps, CE; Douglas, PS
Published in: J Am Heart Assoc
December 13, 2013

BACKGROUND: Exercise testing with echocardiography or myocardial perfusion imaging is widely used to risk-stratify patients with suspected coronary artery disease. However, reports of diagnostic performance rarely adjust for referral bias, and this practice may adversely influence patient care. Therefore, we evaluated the potential impact of referral bias on diagnostic effectiveness and clinical decision-making. METHODS AND RESULTS: Searching PubMed and EMBASE (1990-2012), 2 investigators independently evaluated eligibility and abstracted data on study characteristics and referral patterns. Diagnostic performance reported in 4 previously published meta-analyses of exercise echocardiography and myocardial perfusion imaging was adjusted using pooled referral rates and Bayesian methods. Twenty-one studies reported referral patterns in 49 006 patients (mean age 60.7 years, 39.6% women, and 0.8% prior history of myocardial infarction). Catheterization referral rates after normal and abnormal exercise tests were 4.0% (95% CI, 2.9% to 5.0%) and 42.5% (36.2% to 48.9%), respectively, with odds ratio for referral after an abnormal test of 14.6 (10.7 to 19.9). After adjustment for referral, exercise echocardiography sensitivity fell from 84% (80% to 89%) to 34% (27% to 41%), and specificity rose from 77% (69% to 86%) to 99% (99% to 100%). Similarly, exercise myocardial perfusion imaging sensitivity fell from 85% (81% to 88%) to 38% (31% to 44%), and specificity rose from 69% (61% to 78%) to 99% (99% to 100%). Summary receiver operating curve analysis demonstrated only modest changes in overall discriminatory power but adjusting for referral increased positive-predictive value and reduced negative-predictive value. CONCLUSIONS: Exercise echocardiography and myocardial perfusion imaging are considerably less sensitive and more specific for coronary artery disease after adjustment for referral. Given these findings, future work should assess the comparative ability of these and other tests to rule-in versus rule-out coronary artery disease.

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Published In

J Am Heart Assoc

DOI

EISSN

2047-9980

Publication Date

December 13, 2013

Volume

2

Issue

6

Start / End Page

e000505

Location

England

Related Subject Headings

  • Severity of Illness Index
  • Referral and Consultation
  • ROC Curve
  • Prognosis
  • Predictive Value of Tests
  • Practice Patterns, Physicians'
  • Odds Ratio
  • Myocardial Perfusion Imaging
  • Middle Aged
  • Male
 

Citation

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Chicago
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Ladapo, J. A., Blecker, S., Elashoff, M. R., Federspiel, J. J., Vieira, D. L., Sharma, G., … Douglas, P. S. (2013). Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease. J Am Heart Assoc, 2(6), e000505. https://doi.org/10.1161/JAHA.113.000505
Ladapo, Joseph A., Saul Blecker, Michael R. Elashoff, Jerome J. Federspiel, Dorice L. Vieira, Gaurav Sharma, Mark Monane, Steven Rosenberg, Charles E. Phelps, and Pamela S. Douglas. “Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease.J Am Heart Assoc 2, no. 6 (December 13, 2013): e000505. https://doi.org/10.1161/JAHA.113.000505.
Ladapo JA, Blecker S, Elashoff MR, Federspiel JJ, Vieira DL, Sharma G, et al. Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease. J Am Heart Assoc. 2013 Dec 13;2(6):e000505.
Ladapo, Joseph A., et al. “Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease.J Am Heart Assoc, vol. 2, no. 6, Dec. 2013, p. e000505. Pubmed, doi:10.1161/JAHA.113.000505.
Ladapo JA, Blecker S, Elashoff MR, Federspiel JJ, Vieira DL, Sharma G, Monane M, Rosenberg S, Phelps CE, Douglas PS. Clinical implications of referral bias in the diagnostic performance of exercise testing for coronary artery disease. J Am Heart Assoc. 2013 Dec 13;2(6):e000505.
Journal cover image

Published In

J Am Heart Assoc

DOI

EISSN

2047-9980

Publication Date

December 13, 2013

Volume

2

Issue

6

Start / End Page

e000505

Location

England

Related Subject Headings

  • Severity of Illness Index
  • Referral and Consultation
  • ROC Curve
  • Prognosis
  • Predictive Value of Tests
  • Practice Patterns, Physicians'
  • Odds Ratio
  • Myocardial Perfusion Imaging
  • Middle Aged
  • Male