Reduce Inappropriate Cardiac Stress Testing by Improving Adherence to Educational Guidelines

Abstract

Purpose: This quality improvement initiative aimed to educate primary care providers about theindications and contraindications for nuclear and non-nuclear cardiac stress testing to promote appropriate test selection and improve patient outcomes. Background: Cardiovascular disease is the leading cause of death in the United States, with coronary artery disease responsible for more than half of all cardiovascular events in adults under 75 (Chou, 2015). Although cardiac stress testing is essential for evaluating CAD, 5%–25% of imaging tests are performed inappropriately, resulting in unnecessary radiation exposure, increased costs, and potential patient harm (Chaudhuri et al., 2015). Selecting the correct test relies on following evidence-based guidelines and accurately assessing patient symptoms and clinical status. Methods: A pre-implementation chart audit revealed that 4–13% of stress tests required modification due to inappropriate orders, highlighting the need for provider education. Using a Plan-Do-Study-Act framework, a 30-minute educational intervention was delivered to four primary care providers. Content included types of stress tests, indications, contraindications, and a clinical flowchart tool to guide test selection. Pre- and post-intervention surveys assessed knowledge, confidence, and intent to apply the materials. A four-week post-implementation chart audit evaluated improvements in ordering accuracy. Results: Provider understanding of stress test types improved from 50% agreement before the intervention to 100% agreement or strong agreement afterward. Confidence in selecting appropriate tests rose from 25% to 75%. Knowledge of contraindications increased from 25% to 100%. Confidence in interpreting guidelines grew from 0% to 75%. All providers reported they would use the flowchart in practice. Post-implementation audit findings indicated that 87.5% (7 of 8) of stress test orders were appropriate. Conclusion: Targeted education and practical decision-support tools significantly improved provider knowledge, confidence, and accuracy when ordering cardiac stress tests. Using evidence-based guidance can lower unnecessary imaging, improve workflow efficiency, and reduce patient risk.