Current clinical guidelines advise against routine electrocardiograms (ECGs) in low-risk, asymptomatic patients. However, a population-based retrospective cohort study published July 10 in JAMA Internal Medicine, found ECG testing continues to be relatively common after a patient’s annual health examination (AHE) and leads to more downstream cardiac care. 

R. Sacha Bhatia, MD, et al., analyzed the records for 3,629,859 adult patients in Ontario, Canada who had at least one AHE between the fiscal years of 2010-2011 and 2014-2015. Of the total study population, one-fifth had an ECG within 30 days of an AHE. Fifty-two percent of patients received an ECG on the same day as their AHE, while 78 percent received an ECG within seven days.

The results also show that those who received an ECG were five times more likely to have another cardiac test, procedure or consultation within 90 days of an AHE than those who did not (p < 0.001). They were also more likely to be male and older. Patients living in urban areas and/or with rheumatological disease and cancer were more likely to have an ECG. Yet, the rates of death, cardiac-related hospitalizations and coronary revascularizations were low in both groups.

Significant variations by practice, physician and region for ordering ECGs post AHE were also found. Among the 679 primary care practices, this ranged from 2 percent to 76 percent of patients and among the 8,036 primary care physicians this ranged from 1 percent to 95 percent. “Physician factors associated with ECG ordering were male sex, international medical graduate status, and having practiced for longer than 30 years,” write the authors.

The researchers conclude, “This data lends further evidence to the current guidelines recommending against routine ECGs in low-risk patients […] Our findings suggest that even low-cost procedures […] can lead to more advanced testing that adds cost with little potential benefit to patients.”

They add, “quality improvement interventions to reduce low-value care could be designed to more effectively target practices and physicians with high ordering rates to reduce the prevalence of low-value cardiac testing,” suggesting “the use of audit and feedback, decision support tools, and education.”

Keywords: Physicians, Primary Care, Retrospective Studies, Quality Improvement, Ontario, Research Personnel, Electrocardiography, Internal Medicine, Primary Health Care, Referral and Consultation, Hospitalization, Neoplasms, Canada

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