Research

JAMA Internal Medicine | Original Investigation | LESS IS MORE

Electrocardiograms in Low-Risk Patients

Undergoing an Annual Health Examination
R. Sacha Bhatia, MD, MBA; Zachary Bouck, MPH; Noah M. Ivers, MD, PhD; Graham Mecredy, MSc;
Jasjit Singh, BSc; Ciara Pendrith, MSc; Dennis T. Ko, MD, MSc; Danielle Martin, MD; Harindra C. Wijeysundera, MD, PhD;
Jack V. Tu, MD, PhD; Lynn Wilson, MD; Kimberly Wintemute, MD; Paul Dorian, MD; Joshua Tepper, MD;
Peter C. Austin, PhD, MSc; Richard H. Glazier, MD, MPH; Wendy Levinson, MD

Supplemental content
IMPORTANCE Clinical guidelines advise against routine electrocardiograms (ECG) in low-risk,
asymptomatic patients, but the frequency and impact of such ECGs are unknown.

OBJECTIVE To assess the frequency of ECGs following an annual health examination (AHE)
with a primary care physician among patients with no known cardiac conditions or risk
factors, to explore factors predictive of receiving an ECG in this clinical scenario, and to
compare downstream cardiac testing and clinical outcomes in low-risk patients who did and
did not receive an ECG after their AHE.

DESIGN, SETTING, AND PARTICIPANTS A population-based retrospective cohort study using

administrative health care databases from Ontario, Canada, between 2010/2011 and
2014/2015 to identify low-risk primary care patients and to assess the subsequent outcomes
of interest in this time frame. All patients 18 years or older who had no prior cardiac medical
history or risk factors who received an AHE.

EXPOSURES Receipt of an ECG within 30 days of an AHE.

MAIN OUTCOMES AND MEASURES Primary outcome was receipt of downstream cardiac
testing or consultation with a cardiologist. Secondary outcomes were death, hospitalization,
and revascularization at 12 months.

RESULTS A total of 3 629 859 adult patients had at least 1 AHE between fiscal years
2010/2011 and 2014/2015. Of these patients, 21.5% had an ECG within 30 days after an AHE.
The proportion of patients receiving an ECG after an AHE varied from 1.8% to 76.1% among
679 primary care practices (coefficient of quartile dispersion [CQD], 0.50) and from 1.1% to
94.9% among 8036 primary care physicians (CQD, 0.54). Patients who had an ECG were
significantly more likely to receive additional cardiac tests, visits, or procedures than those
who did not (odds ratio [OR], 5.14; 95% CI, 5.07-5.21; P < .001). The rates of death (0.19% vs
0.16%), cardiac-related hospitalizations (0.46% vs 0.12%), and coronary revascularizations
(0.20% vs 0.04%) were low in both the ECG and non-ECG cohorts.

CONCLUSIONS AND RELEVANCE Despite recommendations to the contrary, ECG testing after
an AHE is relatively common, with significant variation among primary care physicians.
Routine ECG testing seems to increase risk for a subsequent cardiology testing and
consultation cascade, even though the overall cardiac event rate in both groups was very low.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: R. Sacha
Bhatia, MD, MBA, Institute for Health
Systems Solutions and Virtual Care,
Women’s College Hospital,
76 Grenville St, 6th Floor,
JAMA Intern Med. 2017;177(9):1326-1333. doi:10.1001/jamainternmed.2017.2649 Toronto, ON M5S 1B1, Canada
Published online July 10, 2017. (sacha.bhatia@wchospital.ca).

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 Electrocardiograms in Low-Risk Patients
L
ow-value care, defined as care where there is a lack of
benefit or where the benefits are outweighed by the po-
tential risks, can lead to higher health care costs, pa-
tient inconvenience, and in some cases harm to patients.1-3
Resting electrocardiography (ECG) in low-risk patients under-
going an annual health examination (AHE) by a primary care
physician is an example of low-value care. In 2012, the United
States Preventive Services Task Force (USPSTF) recom-
mended against routine ECG screening in low-risk patients be-
cause there is inadequate evidence for the added utility of ECG
in the diagnosis of coronary disease.4 The Choosing Wisely
campaign, launched in 2012, also saw multiple specialty so-
cieties include a recommendation against noninvasive car-
diac testing in low-risk or asymptomatic patients in their top
5 lists of low-value tests, treatments, and procedures that
physicians and patients should question.5
As interest in curbing low-value care increases, accurate
estimates of the utilization of low-value care and its costs and
impact on patient outcomes are vital.6 While prior research has
estimated the frequency of ECGs in selected low-risk patient
groups, population-wide usage of ECGs in low-risk patients and
in particular its impact on costs and cardiovascular outcomes
is unknown.7-9 Understanding the association between low-
value cardiac testing and subsequent health care utilization and
outcomes is essential in the face of concerns regarding rising
cardiovascular testing utilization.10,11
The aim of this study is to quantify the frequency of ECGs
ordered after an AHE in low-risk primary care patients with no
prior cardiac medical history. In addition, we examined
whether such ECGs are associated with subsequent cardiac
tests or consultations and/or patient outcomes.
Methods
Study Design and Data Sources
We conducted a retrospective cohort study in Ontario, Canada,
using linked population-based administrative health care
databases. The data sets were linked using unique encoded
identifiers and analyzed at the Institute for Clinical Evalua-
tive Sciences (ICES). Patients were included if they were an
Ontario resident with a valid health card number and had at
least 1 claim for an annual health examination (AHE) with a pri-
mary care physician (ie, a family physician), between April 1,
2010, and March 31, 2015. Index AHE claims were identified
via Ontario Health Insurance Plan (OHIP) billing codes for either
a periodic health visit (PHV) or an AHE conducted on a healthy
adult patient (aged 18 years or older).12 The general AHE code
was replaced by the PHV in 2013.13 Similar to an AHE with a
healthy patient, the newer PHV is defined as a service per-
formed on “healthy patients who have no apparent medical
problems. The physician and patient can use the appoint-
ment to discuss prevention like screening for cancer and other
health issues relevant to the individual patient’s medical his-
tory and lifestyle.”13 Beyond the PHV having differential bill-
ing codes for different aged patients, there are no practical dif-
ferences between the AHE and PHV, 13 and so both were
considered interchangeable for this anaylsis. We excluded pa-
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Original Investigation Research
Key Points
Question How frequently are electrocardiograms (ECG) ordered
as part of an annual health examination (AHE) and what is the
impact of an ECG on downstream cardiac testing?
Findings In this population-based cohort study of 3 629 859 adult
patients who had an AHE, 21.5% had an ECG within 30 days of an
AHE. Those who had an ECG were 5 times more likely to have
another cardiac test or consultation than those who did not.
Meaning Electrocardiograms conducted on patients as part of an
AHE are common and are associated with more cardiac tests and
consultations.
tients residing in long-term care or with incomplete demo-
graphic data. Patients with physician visits, emergency de-
partment visits, or hospitalizations suggesting significant
cardiovascular disease or cardiovascular risk within 3 years
prior to their AHE were deemed high-risk (eg, prior myocar-
dial infarction, hypertension, diabetes) and excluded through
application of diagnostic codes from OHIP and International
Statistical Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) codes from the Discharge Abstract
Database (DAD).7,14,15 Patients with prior cardiac-related pro-
cedures (eg, aortic valve replacement, coronary artery revas-
cularization), hospitalizations, or consultations were also
excluded using ICD-10 and Canadian Classification of Health
Interventions (CCI) codes.14 We excluded patients with a his-
tory of diabetes and hypertension using the Ontario Diabetes
Database and the Ontario Hypertension Database. eAppen-
dix 1 in the Supplement details the full extent of inclusion and
exclusion criteria, including data sources and associated codes.
Several data sources were used to define patient- and
physician-level characteristics to describe the patient cohort
and create multivariable statistical models. Demographic data
on patients (ie, age, sex, rurality), were obtained from the Reg-
istered Persons Database (RDPB). Quintiles of median neigh-
borhood income were used to approximate patients’ socio-
economic status.16 Any hospitalizations (except those for
cardiac-related reasons) within 3 years prior of the index ex-
amination were determined from DAD ICD-10 codes. OHIP and
DAD were used to determine patients’ history of cancer, chronic
obstructive pulmonary disease (COPD), asthma, dementia,
mental illness, and rheumatoid arthritis within 3 years prior
to study entry. Whether or not a patient was rostered to a regu-
lar primary care physician was determined through cross-
referencing Client Agency Program Enrolment (CAPE) tables
and OHIP fee codes. Ontario introduced formal rostering in its
primary care patient enrolment models in 2001 and during the
study period most (70%) Ontarian patients were rostered.17
Physician-level variables were primarily identified by linking
physicians from patients’ OHIP claims with the ICES Physi-
cians Database (IPDB) to determine physician sex, years since
graduation, and international medical graduate status. The
CAPE tables and OHIP claims were used to classify primary care
practice groups (hereby referred to as practices).18,19 These prac-
tices consisted of 3 or more physicians submitting joint claims
(Reprinted) JAMA Internal Medicine September 2017 Volume 177, Number 9 1327
 Research Original Investigation
Figure 1. Initial Study Cohort
18 863 332 All Ontarians in database
15 233 473 Excluded
4 933 536 Died prior to April 1, 2010,
older than 105 years, or born
after March 31, 2014
92 553 Long-term care residents
4 730 736 High-risk criteria
5 445 244 No routine examination
31 404 Missing income quintile,
LHIN, or rurality
3 629 859 Primary cohort
756 502 Excluded
Could not be linked to a practice
(3 or more physicians submitting joint
claims to OHIP)
2 873 357 Included in analysis
LHIN indicates Local Health Integration Network; OHIP, Ontario Health
Insurance Plan.
to the Ministry of Health and Long Term Care for reimburse-
ment (ie, billing groups).19 Payment models were noted and
any practices consisting of fewer than 3 physicians were
excluded for privacy reasons.
Research ethics approval was received from Sunnybrook
Health Sciences Centre, Toronto, Ontario, Canada. Patient con-
sent was waived because all data were deidentified.
Low-Value Cardiac Care
The primary outcome was low-value cardiac care, defined as
patient receipt of at least 1 ECG within 30 days of a patient’s
index AHE.8 Ontario Health Insurance Plan claims were used
to identify any electrocardiography performed on the patient
in that timeframe.
Downstream cardiac care was identified using OHIP claims.
Receipt of either a consultation with a cardiologist or cardiac
surgeon, transthoracic echocardiogram (TTE), stress test,
nuclear stress test, and/or cardiac catheterization procedure
were measured where claims occurred within 90 days of an
eligible AHE.
Cardiac outcomes, including death, cardiac-related hos-
pitalizations, and coronary revascularization procedures
were captured within 12 months of the index AHE. Death
was identified via the RPBD, whereas the latter events were
identified using DAD ICD-10 codes and CCI codes, respec-
tively. Percutaneous coronary interventions (PCI) and coro-
nary artery bypass grafts (CABG) were also identified using
OHIP claims data.
Statistical Analysis
Unadjusted 30-day ECG rates were calculated separately at the
level of individual regions, practices, and physicians between
fiscal years 2010/2011 and 2014/2015. Regions were defined
by Ontario’s 14 Local Health Integration Networks (LHINs)—
geographically organized administrative regions that plan, in-
tegrate, and fund local health care. Variation in ordering rates was
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Electrocardiograms in Low-Risk Patients
assessed at each level by calculating the coefficient of quartile
deviation, a potentially more robust alternative to the coefficient
of variation.20 All statistical analyses were performed using SAS
statistical software (version 9.4, SAS Institute).
Hierarchical random-intercept multivariable logistic
regression models were used to assess the association of
patient- and physician-level characteristics with the occur-
rence of an ECG within 30 days post-AHE. Owing to the
physician-level characteristics included in these models, only
patients who could be linked to a family physician belonging
to an identifiable practice were included. To test the sensitiv-
ity of our primary outcome definition, we ran a similar analy-
sis including only patients that had an ECG on the same day
as an AHE.
Through inclusion of random intercepts for each prac-
tice, it was possible to calculate the median odds ratio (MOR),
a measure of the heterogeneity in ordering a post-AHE ECG
among practices.21-23 If one were to repeatedly sample 2 par-
ticipants with the same covariates from different practices
randomly, then the MOR is the relative odds difference be-
tween the participant at higher risk of receiving an ECG and
the participant at the lower risk of receiving an ECG in the me-
dian case.21-23 The MOR always has a value greater than or equal
to 1 because it places the patient belonging to the practice with
higher odds of ordering an ECG in the numerator.21-23 The value
is directly comparable to a fixed effects OR, and is based on a
between-practice variance estimate that is adjusted for all other
factors present in a multilevel model.21 For example, a MOR
of 2.00 suggests, in the median case, 100% higher odds of re-
ceiving an ECG at 1 practice vs another.23 The intracluster cor-
relation coefficient (ICC) was also calculated using the linear
threshold method to estimate the proportion of total vari-
ance in ECG ordering that can be attributed to between-
practice differences.21-23
In addition, hierarchical random-intercept multivariable
logistic regression models were used to assess the impact of
having postvisit ECG on downstream cardiac care and ad-
verse patient outcomes. For each of these additional models,
receipt of an ECG within 30 days post-AHE was the primary
exposure of interest and included as a covariate. To account
for the possibility that a physician’s propensity to order low-
value ECGs may be associated with the propensity to order
downstream care we determined each physician’s ECG order-
ing rate (ie, the proportion of patient AHEs with an ECG or-
dered within 30 days) and then created a variable that strati-
fied physicians into quintiles based on their individual rates.
This factor representing physician ECG ordering quintile was
then included in the regression models for both downstream
care and outcomes.
Results
ECG Status and Corresponding Characteristics
The study cohort consisted of 3 629 859 adult patients with at
least 1 AHE between fiscal years 2010/2011 and 2014/2015 in
Ontario (Figure 1). Demographic and clinical data for all eli-
gible patients are presented in Table 1, along with character-
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 Electrocardiograms in Low-Risk Patients Original Investigation Research

Table1.Patient-andPhysician-LevelCharacteristicsBasedonECGClaimStatus Figure 2. Rates of ECG Ordering by Primary Care Practice

30 Days After Patient’s Index Annual Health Examination, n = 3 629 859
250
No. (%)

Frequency (No. of Practices)

Without ECG With ECG 200
Characteristica (n = 2 849 676) (n = 780 183)
Patient level
150
Age, mean (95% CI), y 37.27 (37.26-37.29) 45.62 (45.59-45.65)
Sex 100
Female 1 750 378 (61.4) 398 494 (51.1)
Male 1 099 298 (38.6) 381 689 (48.9) 50
Rurality
Rural 242 864 (8.5) 34 195 (4.4) 0

81 0
86 5
91 0
96 -95
00
5
11 0
16 5
21 0
26 5
31 0
36 5
41 0
46 5
51 0
56 5
61 0
66 5
71 0
76 75
-8
-8
-9
0-
1
-1
-2
-2
-3
-3
-4
-4
-5
-5
-6
-6
-7
Nonrural 2 606 812 (91.5) 745 988 (95.6)

-1
6-

-
Neighborhood income Proportion With ECG Within 30 Days After
quintile Annual Health Examination, %
1 (Lowest) 497 985 (17.5) 135 679 (17.4)
2 536 914 (18.8) 150 990 (19.4)
3 568 914 (19.9) 156 657 (20.1)
claims occurred on the same day as the AHE, and 78.5% of ECG
4 619 139 (21.7) 169 698 (21.8)
claims were within 7 days of an AHE. Patients who had at least
5 (Highest) 627 204 (22.0) 167 159 (21.4)
1 ECG in the defined follow-up period were more likely to be
Charlson Index, 0 (0-0) 0.01 (0.01-0.01)
mean (95% CI) male and were generally older than those who did not have
Hospital admission 203 998 (7.2) 36 205 (4.6) an ECG. The comorbidity burden was low for the entire co-
in past 3 y
hort, though there were some statistically significant differ-
Cancer 240 641 (8.4) 95 037 (12.2)
COPD 60 405 (2.1) 27 564 (3.5) ences between groups.
Asthma 357 106 (12.5) 76 638 (9.8)
Mental health 382 551 (13.4) 104 897 (13.4) Variation by Region, Practice, and Physician
Dementia 5462 (0.2) 2095 (0.3) Regional variation of ECG ordering ranged from a low of 0.7%
Rheumatologic disease 71 248 (2.5) 36 954 (4.7) in the North West LHIN to 24.4% in the Central LHIN (coeffi-
Primary care physicianb cient of quartile deviation [CQD], 0.71) (eAppendix 2.0 in the
Yes 2 505 716 (87.9) 692 605 (88.8) Supplement). Among 679 practices, the proportion of pa-
No 343 960 (12.1) 87 578 (11.2) tients who received an ECG post-AHE ranged from 1.8% to
Physician levelc 76.1% (CQD, 0.50) as shown in Figure 2. Substantial variation
Sex
was also observed across individual primary care physicians
Female 1 018 811 (40.8) 219 399 (31.8)
(range, 1.1%-94.9%; CQD, 0.54) as shown in eAppendix 2.1 in
Male 1 477 054 (59.2) 470 976 (68.2)
the Supplement. Among the 8036 primary care physicians in-
IMG 549 343 (22.0) 188 113 (27.2)
Years since graduation, 25.50 (25.49-25.51) 27.76 (27.74-27.79)
cluded, 7.2% ordered ECGs on more than 50% of their pa-
mean (95% CI)d tients following an AHE.
Primary care practice
structure
Fee-for-service 528 026 (21.2) 152 988 (22.2) Factors Associated With Ordering an ECG Post-AHE
Family health group 912 547 (36.6) 338 885 (49.1) From the initial study cohort detailed in Figure 1, a total of
Family health network 20 577 (0.8) 2015 (0.3) 2 873 357 adult patients who reported belonging to, and could
Family health 505 475 (20.3) 101 282 (14.7) be linked to, an established practice were eligible for model-
organization
ing of post-AHE ECG receipt status.
Family health team 426 410 (17.1) 59 852 (8.7)
As described in Table 2, older age was associated with in-
Other 102 830 (4.1) 35 353 (5.1)
creased odds of having an ECG within 30 days after an AHE.
Abbreviations: AHE, annual health examination; COPD, chronic obstructive Patients living in a rural area were less likely to have an ECG
pulmonary disease; ECG, electrocardiograms; IMG, international medical
graduate. than those living in urban areas. Patients with rheumatologi-
a
For all characteristics (except mental health), P < .001 across groups defined cal disease and cancer had increased odds of having an ECG.
by post-AHE ECG status, Physician factors associated with ECG ordering were male sex,
b
Variable indicates whether patients were rostered to a primary care physician international medical graduate status, and having practiced for
at study entry. longer than 30 years. The interpractice variation in ECG or-
c
Physician-level variables only available for those patients rostered to a primary dering was significant. The MOR was 2.50, indicating that the
care physician with a reported physician number for linkage (n = 3 186 240).
odds of a patient having a post-AHE ECG at 1 randomly
d
Calculated as the mean number of years since graduation among all physicians
selected high-ordering practice were 150% greater than a pa-
at a given practice.
tient with the same characteristics at another randomly se-
lected, low-ordering practice. Aside from patient age, the ef-
istics of their corresponding primary care physicians and prac- fect of a patients’ practice membership on receipt of an ECG
tice groups. Overall, 21.5% of adult patients had a potentially was stronger than the association observed between the out-
low-value ECG within 30 days of their index AHE, 51.7% of ECG come and any other patient- or physician-level factors. The ICC

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 Research Original Investigation Electrocardiograms in Low-Risk Patients

(n = 42 923), nuclear stress tests (n = 15 651), and cardiac cath-

Table 2. Association of Patient- and Physician-Level Characteristics
With Having a Potentially Low-Value ECG Within 30 Days eterizations (n = 1830).
After an Annual Health Examination in 2 873 357 Patientsa Table 3 presents the final multivariable models for
downstream cardiac care. After adjusting for physician ECG
Fixed Effects Odds Ratio (95% CI)b
Patient characteristics
ordering quintile, patients with an ECG within 30 days of an
Age group, y AHE had significantly higher odds of having further cardiac
45-64 vs 18-44 3.46 (3.44-3.48) tests or consultations compared with those who did not.
≥65 vs 18-44 4.73 (4.67-4.79) There was significant interpractice variation in ordering
Male vs female 1.10 (1.09-1.11) downstream care (cardiac consultations: MOR, 1.47; ICC,
Rural 0.78 (0.77-0.80)c 4.7%; TTEs: MOR, 1.60; ICC, 6.85%), and either form of
Neighborhood income quintile stress test (stress test: MOR, 1.71; ICC, 8.85%; nuclear stress
2 vs 1 (Lowest) 1.07 (1.06-1.08) test: MOR, 1.56; ICC, 6.23%). Cardiac catheterization rate
3 vs 1 (Lowest) 1.11 (1.10-1.12) was low (0.29% vs non-ECG 0.03%) and attempts to model
4 vs 1 (Lowest) 1.14 (1.13-1.15) resulted in nonconvergence in the statistical software (eAp-
5 vs 1 (Lowest) 1.12 (1.11-1.13) pendix 2.3 in the Supplement). Sensitivity analyses for ECGs
Hospital admission in past 3 years 1.02 (1.00-1.03) conducted on the same day showed a similar association
Cancer 1.45 (1.44-1.47) with higher odds of ordering additional cardiac testing
COPD 1.07 (1.05-1.08) within 90 days (eAppendix 2.4 in the Supplement).
Asthma 0.86 (0.85-0.87) The overall rates of adverse clinical outcomes at 1-year post-
Mental health 1.06 (1.05-1.07)
AHE were extremely low in both groups. The unadjusted rate
Dementia 0.86 (0.81-0.91)
of each outcome was higher in the ECG vs the non-ECG group,
Rheumatologic disease 1.27 (1.25-1.29)
including death (0.19% vs 0.16%), cardiac-related hospitaliza-
Physician characteristics
tions (0.46% vs 0.12%), and coronary revascularizations (0.20%
Male vs female 1.11 (1.10-1.12)
vs 0.04%) (eAppendix 2.5 in the Supplement). Only the de-
IMG 1.13 (1.12-1.14)
scriptive statistics are presented for these outcomes because
Years since graduation (mean)
their corresponding regression models each failed to con-
21-30 vs 0-20 1.04 (1.04-1.05)
>30 vs 0-20 1.15 (1.14-1.16)
verge in the statistical software.
Organizational structure
Family health group vs FFS 1.55 (1.54-1.57)
Family health network vs FFS 1.22 (1.06-1.40)
Discussion
Family health organization vs FFS 1.31 (1.28-1.35)
Family health team vs FFS 0.99 (0.97-1.02) In this large, retrospective cohort study, we found that de-
Other vs FFS 1.64 (1.59-1.70) spite recommendations against ECGs in low-risk patients un-
Random effect dergoing a routine AHE with a primary care physician, this prac-
Practicec 2.50 (2.40-2.60) tice seemed to be common. Importantly, we demonstrated that
Abbreviations: COPD, chronic obstructive pulmonary disease; patients who received an ECG 30 days post-AHE were more
ECG, electrocardiograms; FFS, fee for service. than 5 times more likely to also receive another cardiac test,
a
All reported values based on SAS (version 9.4) PROC GLIMMIX output; model procedure, or consultation with a specialist. These down-
estimation method = RSPL; denominator degrees of freedom estimation stream cardiac tests and procedures also demonstrated sig-
method = between and within; covariance structure = standard variance.
nificant practice variation even after adjustment for patient and
P < .05 for all variables except family health team vs FFS (P=.71)
b physician factors. Finally, both groups of patients exhibited low
All odds ratios presented are adjusted for all other factors in the table.
c combined rates of death, cardiac-related hospitalizations, and
Median odds ratio reported with 95% CI in parentheses.
coronary revascularizations in the ensuing year.
These findings support earlier results that show high rates
of potentially low-value ECGs in primary care patients. Previ-
estimate indicates that 21.9% of the total variation in post- ous studies have shown the frequency of ECGs in low-risk
AHE ECG use can be attributed to practice-level variation. Based patients to be between 9% to 12% in various populations,
on the sensitivity analysis, all of the characteristics signifi- including both Medicare and commercial payers, with simi-
cantly associated with increased odds of having an ECG at 30 lar degrees of regional variation to this study.7-9 Where this
days post-AHE were similarly associated with same-day study differs is that it includes an entire population from a
receipt of an ECG (eAppendix 2.2 in the Supplement). single-payer, publicly funded system, allowing for a more ro-
bust analysis of ordering practices. We also found significant
Association of Post-AHE ECG With Downstream Cardiac Care variation in ordering between regions, practices, and even phy-
Overall, 5.3% of patients with an AHE had a cardiac-related con- sicians that cannot be explained by patient factors such as
sultation, test, or procedure within 90 days following their pri- comorbidities. This striking ordering variation, which has been
mary care physician AHE. Cardiac care included consulta- noted in both primary care and hospital-based ordering prac-
tions with a cardiologist or cardiac surgeon (n = 36 085), tices in previous work, provides potential opportunities for
transthoracic echocardiograms (TTE, n = 83 463), stress tests improvements in ordering practices, particularly among high-

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 Electrocardiograms in Low-Risk Patients Original Investigation Research

Table 3. Patient- and Physician-Level Indicators for a Downstream Cardiac Consultation, Test, or Procedure in 2 352 324 Patients Within 3 Months
After an Annual Health Examination Based on a Multilevel Logistic Regression With a Random Intercept for Practice-Level Effects

OR (95% CI)a
Cardiac Consultations TTE Stress Test Nuclear Stress Test
Fixed Effects (n = 36 085) (n = 83 463) (n = 42 923) (n = 15 651)
Patient characteristics
ECG by AHE after 30 daysb 5.38 (5.24-5.52)c 7.09 (6.97-7.22)c 6.48 (6.33-6.64)c 4.21 (4.04-4.38)c
Physician ECG ordering quintile
2 vs 1 (lowest) 1.03 (0.99-1.08) 1.18 (1.14-1.23)c 1.08 (1.03-1.13)c 1.01 (0.94-1.09)c
c c
3 vs 1 (lowest) 1.00 (0.95-1.04) 1.28 (1.23-1.33) 1.21 (1.15-1.26) 1.03 (0.95-1.11)
4 vs 1 (lowest) 0.73 (0.70-0.77)c 1.09 (1.05-1.13)c 0.91 (0.87-0.96)c 0.91 (0.85-0.99)c
5 vs 1 (lowest) 0.37 (0.35-0.39)c 0.60 (0.58-0.63)c 0.53 (0.50-0.55)c 0.61 (0.57-0.66)c
Age group, y
45-64 vs 18-44 1.62 (1.58-1.67)c 1.27 (1.25-1.29)c 1.81 (1.77-1.85)c 3.47 (3.33-3.63)c
≥65 vs 18-44 2.77 (2.68-2.87)c 1.97 (1.92-2.02)c 1.74 (1.68-1.81)c 6.25 (5.92-6.59)c
Male vs female 1.75 (1.71-1.79)c 1.23 (1.21-1.25)c 1.79 (1.75-1.83)c 1.32 (1.28-1.37)c
Neighborhood income quintile
2 vs 1 (Lowest) 1.02 (0.98-1.05) 0.91 (0.89-0.93)c 0.95 (0.92-0.98)c 0.95 (0.90-1.01)
3 vs 1 (Lowest) 1.01 (0.98-1.05) 0.92 (0.90-0.95)c 0.97 (0.94-1.01) 0.94 (0.89-0.99)c
4 vs 1 (Lowest) 1.03 (0.99-1.07) 0.89 (0.87-0.91)c 0.97 (0.94-1.01) 0.95 (0.90-1.00)
5 vs 1 (Lowest) 1.04 (1.00-1.07) 0.89 (0.87-0.92)c 0.96 (0.93-0.99)c 0.93 (0.88-0.98)c
Hospital admission last 3 y 1.48 (1.42-1.54)c 0.94 (0.91-0.97)c 0.85 (0.81-0.90)c 1.02 (0.95-1.10)
Cancer 1.75 (1.70-1.80)c 1.09 (1.07-1.12)c 1.02 (0.99-1.05) 1.77 (1.70-1.84)c
c
COPD 1.16 (1.11-1.21) 1.04 (1.00-1.07) 1.03 (0.98-1.08) 1.25 (1.17-1.33)c
Asthma 1.06 (1.02-1.09)c 0.99 (0.97-1.01) 0.94 (0.91-0.97)c 1.00 (0.95-1.06)
Mental health 1.23 (1.20-1.27)c 0.99 (0.97-1.01) 1.00 (0.97-1.03) 1.09 (1.04-1.14)c
c
Dementia 1.48 (1.31-1.68) 0.98 (0.88-1.11) 0.89 (0.75-1.06) 1.00 (0.82-1.23)
Rheumatologic disease 1.44 (1.39-1.51)c 1.03 (1.00-1.06) 0.97 (0.93-1.02) 1.21 (1.14-1.28)c
Rural 1.02 (0.97-1.07) 0.98 (0.88-1.10) 1.00 (0.96-1.05) 0.87 (0.8-0.94)c
Physician characteristics
Sex
Male 0.96 (0.94-0.99)c 1.00 (0.98-1.01) 0.96 (0.93-0.98)c 1.09 (1.05-1.13)c
Female 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]
IMG 1.14 (1.11-1.17)c 1.14 (1.12-1.16)c 1.11 (1.08-1.14)c 1.19 (1.15-1.24)c
Years since graduation (mean), y
21-30 vs 0-20 0.93 (0.90-0.95)c 0.95 (0.93-0.96)c 0.87 (0.85-0.90)c 0.88 (0.85-0.92)c
>30 vs 0-20 0.89 (0.87-0.92)c 0.88 (0.87-0.90)c 0.77 (0.75-0.80)c 0.86 (0.82-0.90)c
Organizational structure
Family health group vs FFS 0.87 (0.83-0.90)c 0.85 (0.83-0.87)c 0.82 (0.79-0.85)c 0.87 (0.82-0.93)c
Family health network vs FFS 1.01 (0.74-1.37) 1.15 (0.89-1.50) 0.59 (0.41-0.85)c 0.79 (0.49-1.27)
Family health organization vs FFS 0.88 (0.83-0.92)c 0.83 (0.79-0.86)c 0.89 (0.84-0.94)c 0.79 (0.73-0.86)c
Family health team vs FFS 0.98 (0.93-1.04) 0.92 (0.88-0.96)c 0.98 (0.92-1.05) 0.82 (0.76-0.90)c
Other vs FFS 0.87 (0.78-0.97)c 0.55 (0.52-0.59)c 0.87 (0.78-0.97)c 0.83 (0.70-0.97)c
Random effects
Practiced 1.47 (1.45-1.49)c 1.60 (1.57-1.63)c 1.71 (1.68-1.75)c 1.56 (1.53-1.60)c
Abbreviations: AHE, annual health examination; COPD, chronic obstructive method = between and within; covariance structure = standard variance.
pulmonary disease; ECG, electrocardiograms; OR, odds ratio; TTE, transthoracic b
Indicates patient had an ECG within 30 days after AHE.
echocardiogram. c
P < .05.
a
All odds ratios presented are adjusted for all other factors in the table. All d
Median odds ratio reported with 95% CI in parentheses.
reported values based on SAS (version 9.4) PROC GLIMMIX output; model
estimation method = RSPL; denominator degrees of freedom estimation

ordering physicians, because there were a small number of phy-
sicians that ordered ECGs on most of their patients.24,25 Most
importantly, we demonstrate that ECGs in this low-risk popu-
lation leads to further downstream cardiac testing and con-
sultations that add to health care costs.
One of the most important findings of this study was the
higher rates of further cardiac testing or cardiology consulta-
tions in patients who had an ECG. The diagnostic cascade is a
described phenomenon where higher rates of noninvasive
diagnostic testing lead to higher rates of more invasive diag-
nostic testing and therapeutic interventions.26-29 For ex-
ample, Shah and colleagues26 found higher rates of routine
stress testing after coronary revascularization lead to higher
rates of repeated revascularization with no impact on death
or repeated myocardial infarction. To date, however, this find-
ing has not been shown in resting ECG testing, which is most
commonly done in primary care offices in patients who often
do not have a medical history of cardiac disease. The higher

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 Research Original Investigation Electrocardiograms in Low-Risk Patients

rates of further testing or consultations, like ECG ordering, were
independent of patient comorbidities; it is probable that inci-
dentally discovered abnormalities found on ECG precipitated
further testing and cardiology consultations.
The low event rates in patients who received and did not
receive an ECG as part of an AHE add more evidence to the rec-
ommendation against using ECGs as a risk stratification tool.
Systematic reviews have found no randomized clinical trials
or large prospective cohort studies on the effects of ECGs or-
dered in low-risk patients vs no ECG on clinical outcomes or
costs.4,30 Despite this lack of evidence there still remains some
debate as to the utility of ECGs as a risk stratification tool.29
Our findings in a large, population-based cohort study show
very low event rates that were less than 1% in both groups, de-
spite higher rates of cardiovascular investigations in the ECG
group. This data lends further evidence to the current guide-
lines recommending against routine ECGs in low-risk
patients, which appear to lead to higher health care utiliza-
tion with questionable clinical benefit.
The results of this study have considerable health care
policy implications. First, when selecting overuse metrics for
quality improvement initiatives, consideration should be given
to the impact on downstream testing and outcomes.31,32 Some
of the past criticism of the Choosing Wisely recommenda-
tions is that they are often of seemingly little consequence, with
specialty societies avoiding big-ticket items like surgical pro-
cedures, or more advanced diagnostic tests.33 Our findings sug-
gest that even low-cost procedures, like ECGs in low-risk
patients occur with considerable frequency, and importantly
can lead to more advanced testing that adds costs with little
potential benefit to patients. Second, measurement of low-
value care should also attempt to quantify the impact on health
outcomes for patients.6 Finally, quality improvement inter-
ventions 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, and
the unexplained ordering variation.34 In particular, prior
research has shown that the use of audit and feedback, deci-
sion support tools, and education could reduce low-value
cardiac testing, and similar types of interventions could be used
in some combination to reduce low-value care.24,35-37
Limitations
The results must be interpreted in the context of several limi-
tations. Administrative databases do not provide important
clinical information, such as presence of symptoms or abnor-
mal physical examination findings that are necessary to de-
termine appropriateness of further testing orders. In this
instance, we are unable to determine whether a patient had
an ECG for screening, or if the patient had symptoms or signs
that warranted a diagnostic test. However, usually a visit will
not be coded as an AHE if there is a specific cardiac symptom
that is the focus of the assessment. It is also possible that some
physicians ordered an ECG prior to the AHE that were not cap-
tured. We also do not have the results of the ECGs, which would
almost certainly have influenced further cardiac investiga-
tions. Finally, it is possible that practice or regional factors not
identified by available data may play a role in the degree of
ordering variation seen, which may be an opportunity for
future studies. Despite these limitations, this study provides
important new information about the use and impact of low-
value cardiac testing in the primary care setting.
Conclusions
In this large, population-based retrospective study, we found
21.5% of low-risk patients received an ECG within 30 days fol-
lowing an AHE, with significant regional-, practice-, and
physician-level ordering variation. Moreover, low-risk pa-
tients who received an ECG also had a higher likelihood of fur-
ther cardiac tests, procedures, and cardiologist consultations.

ARTICLE INFORMATION
Accepted for Publication: May 1, 2017.
Published Online: July 10, 2017.
doi:10.1001/jamainternmed.2017.2649
Author Affiliations: Institute for Health Systems
Solutions and Virtual Care, Women’s College
Hospital, Toronto, Ontario, Canada (Bhatia, Bouck,
Ivers, Martin); Institute for Clinical Evaluative
Sciences (ICES), Toronto, Ontario, Canada (Bhatia,
Ivers, Mecredy, Ko, Wijeysundera, Tu, Austin);
Institute for Health Policy, Management, and
Evaluation (IHPME), University of Toronto, Toronto,
Ontario, Canada (Ivers, Martin, Wijeysundera,
Austin); Department of Family and Community
Medicine, University of Toronto, Toronto, Ontario,
Canada (Ivers, Martin, Wilson, Wintemute, Tepper,
Glazier); University of Ottawa Medical School,
Ottawa, Ontario, Canada (Singh); Cumming School
of Medicine, University of Calgary, Calgary, Alberta,
Canada (Pendrith); Schulich Heart Center,
Sunnybrook Health Sciences Center, University of
Toronto, Toronto, Ontario, Canada (Ko,
Wijeysundera, Tu); Department of Medicine,
University of Toronto, Toronto, Ontario, Canada
(Ko, Wijeysundera); Sunnybrook Research Institute
(SRI), Sunnybrook Health Sciences Center, Toronto,
Ontario, Canada (Ko, Wijeysundera); Department of
Family and Community Medicine, Women’s College
Hospital, Toronto, Ontario, Canada (Martin);
Division of Cardiology, University of Toronto,
Toronto, Ontario, Canada (Dorian); Keenan
Research Centre for Biomedical Science,
St Michael’s Hospital, Toronto, Ontario, Canada
(Dorian); Li Ka Shing Knowledge Institute,
St Michael’s Hospital, Toronto, Ontario, Canada
(Dorian); Centre for Urban Health Solutions, Li Ka
Shing Knowledge Institute, St Michael’s Hospital,
Toronto, Ontario, Canada (Glazier, Levinson);
Department of Family and Community Medicine,
St Michael’s Hospital, Toronto, Ontario, Canada
(Glazier); Department of Medicine, University of
Toronto, Toronto, Ontario, Canada (Levinson).
Author Contributions: Dr Bhatia had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Concept and design: Bhatia, Bouck, Pendrith, Ivers,
Tu, Wintemute, Dorian, Tepper, Glazier, Levinson.
Acquisition, analysis, or interpretation of data:
Bhatia, Bouck, Ivers, Singh, Pendrith, Mecredy, Ko,
Martin, Wilson, Dorian, Tepper, Austin, Glazier.
Drafting of the manuscript: Bhatia, Bouck, Ivers,
Singh, Pendrith, Wilson.
Critical revision of the manuscript for important
intellectual content: Bhatia, Bouck, Ivers, Pendrith,
Mecredy, Ko, Martin, Wijeysundera, Tu, Wintemute,
Dorian, Tepper, Austin, Glazier, Levinson.
Statistical analysis: Bhatia, Bouck, Ivers, Singh,
Mecredy, Wijeysundera.
Obtained funding: Bhatia, Levinson.
Administrative, technical, or material support:
Bhatia, Ivers, Pendrith, Tu, Wilson, Dorian.
Study supervision: Bhatia, Dorian, Levinson.
Conflict of Interest Disclosures: Dr Ivers is
supported by New Investigator Awards from the
Canadian Institutes of Health Research and the
Department of Family and Community Medicine,
University of Toronto. Dr Wijeysundera is supported
by the Distinguished Clinician Scientist Award from
the Heart and Stroke Foundation of Canada. Dr
Glazier is supported as a Clinician scientist in the
Department of family and Community Medicine at
St Michael’s Hospital and at the University of
Toronto. Dr Ko is supported by a Mid-Career
Investigator Award from the Heart and Stroke

1332 JAMA Internal Medicine September 2017 Volume 177, Number 9 (Reprinted) jamainternalmedicine.com

© 2017 American Medical Association. All rights reserved.

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 Electrocardiograms in Low-Risk Patients
Foundation, Ontario Provincial Office. Jasjit Singh
was supported by a CIHR sponsored CANHEART
summer student grant. Dr Austin is supported by a
Career Investigator Award from the Heart and
Stroke Foundation, Ontario Provincial Office. No
other disclosures are reported.
Funding/Support: This study was supported by the
Institute for Clinical Evaluative Sciences (ICES),
which is funded in part by an annual grant from the
Ontario Ministry of Health and Long-Term Care
(MOHLTC).
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study; the
collection, management, analysis, or interpretation
of the data; the preparation, review or approval of
the manuscript; or the decision to submit the
manuscript for publication.
Disclaimer: The opinions, results and conclusions
reported in this paper are those of the authors and
are independent from the funding sources. No
endorsement by ICES or the Ontario MOHLTC is
intended or should be inferred. Parts of this
material are based on data and information
compiled and provided by CIHI. However, the
analyses, conclusions, opinions, and statements
expressed herein are those of the authors, and not
necessarily those of CIHI.
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