Cost and appropriateness of radionuclide exercise stress testing by cardiologists and non-cardiologists

The hypothesis that a diagnostic evaluation performed by a generalist is less expensive than that performed by a specialist is untested. We retrospectively evaluated the indications and financial ramifications of radionuclide exercise stress testing by cardiologists and noncardiologists in 1,902 consecutive adults with normal resting electrocardiograms. Subjects completed radionuclide exercise tests for the diagnosis or management of coronary artery disease during a 14-month period. Tests were considered “indicated” or “not indicated” based on criteria determined from published reports and established practice guidelines. Savings in costs and charges were determined for a strategy of referral to a cardiologist before ordering tests. Non-cardiologists ordered more tests that were not indicated than cardiologists (69.6% vs 36.2%, chi-square = 209.07, p < 0.00001). Non-cardiologists also ordered tests that were not indicated in patients with (chi-square = 110.02, p < 0.00001) and without (chi-square = 45.44, p < 0.00001) chest pain. Tests that were not indicated resulted in excess costs of $591,384 and excess charges of $1,082,400. Referral to a cardiologist before ordering tests could have saved $63,257 in costs and $169,800 in charges. Both cardiologists and noncardiologists overutilized radionuclide exercise stress tests; however, non-cardiologists were more likely to order tests that were not indicated. A strategy of referral to a cardiologist before ordering tests may be costeffective in this population.