Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

What are the comparative diagnostic accuracy, diagnostic thinking, therapeutic, and patient outcome efficacy of non-invasive tests for the risk stratification of patients with coronary artery disease?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Interventions will be compared according to type of stress (exercise, vasodilators [dipyridamole and adenosine] and dobutamine) and the measure of induced ischemia (ECG changes with electrocardiography, perfusion defects with radionuclide myocardial perfusion imaging, and wall motion abnormalities with echocardiography)

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients with symptomatic and asymptomatic coronary artery disease

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Asymptomatic patients with a history of revascularization, women vs men, elderly patients

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

All patient-related benefits, including but not limited to: reduction in hospitalizations, major adverse cardiovascular events, and mortality

Describe any health-related risks, side effects, or harms that you are concerned about.

All patient-related harms, including but not limited to: higher utilization of elective cardiac catheterization without subsequent percutaneous coronary intervention, hospitalizations, major adverse cardiovascular events, and mortality

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cardiovascular disease, including stroke and hypertension

AHRQ Priority Populations

• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Multiple stress tests are available to aid in the evaluation of patients at intermediate risk of patients with coronary artery disease. There are both multiple types of stress used (exercise, vasodilators [dipyridamole and adenosine] and dobutamine) and measures of induced ischemia (ECG changes with electrocardiography, perfusion defects with radionuclide myocardial perfusion imaging, and wall motion abnormalities with echocardiography). As a result of the number of combinations of stress and measure of induced ischemia, there are a number of options available for stress testing, and the comparative effectiveness of each diagnostic strategy is unknown. Predictive values, sensitivity, and specificity for each of these diagnostic strategies is known, but their relative impacts on clinical end points – major cardiovascular events, hospitalizations, and mortality – have not been compared. Similarly, comparative utilization of elective cardiac catheterization following each of these diagnostic strategies is not known.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

This topic was ranked as a priority by a panel of stakeholders convened through the Duke EPC’s Cardiovascular Topic Identification project to recommend a research agenda for future systematic reviews within the EHC cardiovascular domain.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Stakeholders considered uncertainty for clinicians and/or policy-makers as part of the ranking process, and with that criterion considered, this topic received a priority designation.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

This topic was identified by a group of stakeholders in cardiovascular disease as an area in which significant morbidity, mortality, and/or variation in resource utilization persists, and future systematic review development should be prioritized. Answers to this question are expected to inform practice and guideline development, and ultimately improve the quality of care by reducing morbidity, mortality, and costs.

Describe the timeframe in which an answer to your question is needed.

Though no specific timeframe is applicable, this topic was identified by the stakeholder group as immediately relevant.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Stakeholders considered variation in clinical practice and inequities in care as part of the ranking process, and with that criterion considered, this topic received a priority designation.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

This topic was identified by a group of stakeholders in cardiovascular disease as an area in which significant morbidity, mortality, and/or variation in resource utilization persists, and future systematic review development should be prioritized. Answers to this question are expected to inform practice and guideline development, and ultimately improve the quality of care by reducing morbidity, mortality, and costs.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Involvement in the Evidence-based Practice Center Program