Why do we do stress tests?

[migm]

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After having listened to the smartem talk on stress tests and having heard the recent guideline change to preferring stress tests prior to discharge on all low risk ACS patients.. are we being silly? why are we making clinical decisions with what seem like crappy tests?

http://www.epmonthly.com/subspecialties/management/special-report-the-truth-about-stress-tests/

 

[GeneralVeers]

After having listened to the smartem talk on stress tests and having heard the recent guideline change to preferring stress tests prior to discharge on all low risk ACS patients.. are we being silly? why are we making clinical decisions with what seem like crappy tests?

http://www.epmonthly.com/subspecialties/management/special-report-the-truth-about-stress-tests/

For the same reason that we give antibiotics for strep throat, otitis media, sinusitis and bronchitis. It makes them think we are doing something for them.

 

[deleted109597]

Also risk mitigation. Don't be the last person to touch anyone.

 

[deleted6669]

we have an e.d. run chest pain unit at my facility where the PAs do stress tests on probably 4-6 pts/day who have already ruled out by 2 sets of enzymes and 2 nl ekg's 6 hrs apart.
we probably have a 5-10% positive rate on these tests which lead folks to get cathed who otherwise would have been sent home. I have had a few impressive positives with significant exertional st depression later showing 90% + occlusions on cath in folks who had "nl" resting ekg's who would have otherwise been sent home after 6 hrs as "atypical chest pain".. most of these are folks in their 40's and 50's.
also the er group can bill for them at 600 bucks/pop.....+ the price of a 6-12 hr obs admission....

 

[xaelia]

I have had a few impressive positives with significant exertional st depression later showing 90% + occlusions on cath in folks who had "nl" resting ekg's who would have otherwise been sent home after 6 hrs as "atypical chest pain"

Anecdotal evidence is the worst evidence. If you don't have information on false-positive and false-negative rates, you have no idea if you're doing more good than harm.

also the er group can bill for them at 600 bucks/pop.....+ the price of a 6-12 hr obs admission....

This.

In addition to the "last touched" argument from McNinja.

 

[deleted6669]

Anecdotal evidence is the worst evidence. If you don't have information on false-positive and false-negative rates, you have no idea if you're doing more good than harm.
.

of the probably 100 tests I have done around 8-10 have gone to cath with 5 or so having high grade lesions requiring stents. one guy had a lg left main lesion and ended up with a CABG as they couldn't stent him.
he had a very impressive treadmill. chest pain with a long run of vtach (with a pulse).
yup, let's call that a positive.
we have close to 20 PAs in our group and my experience is pretty typical of our group. money aside, I think we are helping some folks who ten years ago would have gone home to have their big MI. ( off subject, but we also do TIA workups in the same unit).

 

[VentdependenT]

So we dont get sued

 

[TooMuchResearch]

of the probably 100 tests I have done around 8-10 have gone to cath with 5 or so having high grade lesions requiring stents. one guy had a lg left main lesion and ended up with a CABG as they couldn't stent him.
he had a very impressive treadmill. chest pain with a long run of vtach (with a pulse).
yup, let's call that a positive.
we have close to 20 PAs in our group and my experience is pretty typical of our group. money aside, I think we are helping some folks who ten years ago would have gone home to have their big MI. ( off subject, but we also do TIA workups in the same unit).

I don't think providing more anecdote will satisfy xaelia.

 

[deleted6669]

I don't think providing more anecdote will satisfy xaelia.

probably not. from my personal/anecdotal experience it works out to approx. 10% positive tests with 1/2 of those being real/actionable. ditto for 20 of my colleagues so informally a 5% real positive result to doing treadmills. sorry, can't do better than that with the info I have.

 

[deleted109597]

probably not. from my personal/anecdotal experience it works out to approx. 10% positive tests with 1/2 of those being real/actionable. ditto for 20 of my colleagues so informally a 5% real positive result to doing treadmills. sorry, can't do better than that with the info I have.

He (and the rest of us) isn't arguing that you aren't picking up real pathology.
The argument is: Are we picking up enough real pathology to make it worth it to society to do the test as indiscriminately as we are doing it, and at the same time, are we picking up enough false pathology to make it harmful.

Your anecdotal evidence is the same that some people use to justify their incredibly high CT rates. Sure, some of them pick stuff up. But is that stuff worth the risks?

 

[Bostonredsox]

Because most of them dont have insurance or are medicaid and if we send them home after the brief obs to have an outpt stess in the Cards office the cards attending gives you death threats for flooding them with non-paying patients.

We gots da get PAAAID

 

[DeadCactus]

Because the patient has little to no economic incentive to refuse the test, the physician has strong economic incentives to order the test, and the parties directly or indirectly paying for the test have little say in whether the test is done...

 

[HankReardon]

Because the patient has little to no economic incentive to refuse the test, the physician has strong economic incentives to order the test, and the parties directly or indirectly paying for the test have little say in whether the test is done...

Quoted for truth. Game, set, match.