Electrocardiograms following annual health visit are common despite being low yield

1. Electrocardiograms (ECGs) are performed commonly following annual health visits in low risk patients but with substantial variation between practices and physicians.

2. Patients for whom ECGs are performed are more likely to undergo further cardiac testing. Rates of death, cardiac-related hospitalization, and cardiac procedures remain low in patients regardless of whether ECGs are performed.

Evidence Rating Level: 2 (Good)       

Study Rundown: Low value care refers to medical practices without proven benefit that may be associated with significant cost, need for further diagnostic interventions, and potential harm to the patient. Efforts to reduce low value care have become more prominent with the Choosing Wisely Campaigns. This study evaluated the use of ECGs following annual health exams (AHE) or Periodic Health Visit (PHV) in patients without prior history of cardiac disease or associated conditions. It found that ECGs were commonly performed for patients within 30 days of AHE with substantial variation between practices and physicians. Adjusting for comorbidities did not explain this variation. Performance of ECG was associated with increased rate of downstream cardiac care including cardiology referral, echocardiogram, stress testing, and cardiac catheterizations. Rates of death, cardiac-related hospitalizations, and revisualizations were low in both patients with and without ECGs performed.

The strengths of the study included the large sample size from a single payer system. The main limitation of the study was reliance on administrative data which cannot elucidate whether symptoms or other factors may have influenced the ordering of ECGs in certain patients following AHE.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: Low-Value Medical Services in the Safety-Net Population

In-Depth [retrospective cohort]: This study was a retrospective analysis of patients from Ontario, Canada. It included patients from 2010 to 2015 who underwent at least one AHE or PHV with a primary care physician. Patients with physician or hospital visits with diagnostic codes linked to cardiovascular disease or risk (diabetes, hypertension, etc.) were excluded. Patients were considered as having low-value cardiac care if there was an ECG performed within 30 days of AHE.

A total of 3 629 859 adult patients were included in the analysis with 21.5% of them having ECGs performed following AHE. Patients with ECGs ordered were more likely to be male, older, but there was no observed difference in Charlson comorbidity index. There was significant variation in ECG ordering between geographic regions (0.7%-24.4%, coefficient of quartile deviation [CQD] 0.71), medical practices (1.8%-76.1%, CQD 0.50), and physicians (1.1%-94.9%, CQD 0.54). Further diagnostic tests and cardiac evaluation were more common for patients with AHE-associated ECGs (OR 5.14; 95%CI 5.07-5.21; p < 0.001). The rates of death, cardiac hospitalization, and revascularization were less than 1% for all patients and not statistically different for those with or without ECGs.

Image: PD

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