ECG Study Highlights Risks of Over-Medicalization

July 2017

Survey results released earlier this month found that one in five adult patients in Ontario with no known cardiac conditions or risk factors had an electrocardiogram (ECG) within 30 days of their annual health examination despite guidelines which advise against ECGs in this cohort.

Findings from the ECG study (see Abstractsupport the need for the awareness created by Choosing Wisely Canada's campaign to implement good healthcare stewardship and avoid over-medicalization and the implementation support provided by the OCFP’s Practising Wisely: Reducing Unnecessary Testing and Treatment program.

Here, two of the study’s authors, family physician Dr. Noah Ivers, and cardiologist Dr. R. Sacha Bhatia, who also leads evaluations for Choosing Wisely Canada, answer four questions from OCFP eNews about their findings. 

Photo of Dr. Sacha BhatiaDr. Sacha Bhatia

Photo of Dr. Noah Ivers


Dr. Noah Ivers

OCFP eNews: What do you see as the main factors for family physicians continuing to order routine ECGs for low-risk, asymptomatic patients despite the clinical guidelines? 

Dr. Sacha Bhatia and Dr. Noah Ivers: First, it is important to recognize that the majority of family physicians are actually not ordering these tests in great numbers. This paper actually shows that the vast majority may be using ECGs appropriately. But, there are about seven per cent of family physicians who are ordering these ECGs in more than 50 per cent of their low-risk patients. Relevant literature - and our own experience - suggests that important factors that may be contributing to ordering these ECGs may be force of habit, pre-filled forms, patient expectations or even support staff ordering routine testing.

OCFPYou identify the “consultation cascade” of additional tests as the potential outcome of an initial ECG. How might this be avoided? What role does the relationship between specialists (cardiologists) and family physicians play in preventing this from happening?

SB, NI: There are a number of factors to consider in the consultation cascade. First, good communication between specialists and family physicians is critical. Having the ability to either pick up the phone, email or use a service like e-consultation to quickly get an answer to a question about a potential abnormality on ECG could be very helpful in avoiding a formal consultation and lead to some knowledge translation regarding the clinical significance of some of these tests.

In addition, whether through consult notes, scheduled CME or other formal and informal learning opportunities, specialists could provide guidance to their family medicine colleagues about practical tips to ordering testing and the interpretation of results.

A comprehensive approach like this could lead to not only more targeted test ordering, but also helpful advice as to what to do with the results of those tests.

The challenge is that once the test results is there, it's hard not to go on to the next test. When we're unsure, it would be helpful to discuss the context of the test, in terms of the lack of any concerning symptoms or signs, before we subject the patient to more tests or treatments. When the family physician and cardiologist trust and respect one another, this kind of productive conversation may be more likely. Of course, the cascade cannot begin without the first test - so it’s important that it be ordered only when warranted. That is, when there is a reasonable pre-test probability of disease based on the history and physical exam to help interpret the results.

OCFP: What would you say to family physicians who believe ordering routine ECGs is appropriate and that not ordering an ECG is risky?

SB, NI: The results of our study actually support the opposite viewpoint. In more than 3.6 million patients we found that the one-year outcomes of death, cardiac hospitalizations and revascularization were less than 0.5% in both the ECG and no-ECG groups, whereas those patients who had an ECG were 5 times more likely to get further testing that may expose patients to radiation or even invasive procedures.

So, the evidence here indicates the risks of not doing ECG testing are not supported by data. We understand that changing attitudes takes time and, with campaigns like Choosing Wisely Canada, we hope attitudes towards unnecessary testing will change as well. Especially if we have been used to doing things a certain way, once we address the relevant beliefs, we need to work on the skills involved in explaining this change to patients. Hopefully, patients will appreciate and respect a doctor that aims to adjust his or her practice in keeping with the latest research. 

OCFP: Do you believe practices are changing when it comes to over-medicalization?

SB, NI: To some extent, yes. It requires a change in mindset but the idea of whole person comprehensive care that is at the heart of family practice aligns well with avoiding over testing and over treatment. And it's nice to focus on doing less, rather than the expectation to do more in a brief visit. Hopefully, doing fewer things that are low value allows us time to focus on the implicitly rewarding aspects of clinical encounters – those things that are more likely to positively influence health of our patients. 

Dr. R. Sacha Bhatia is the Director of the Institute for Health System Solutions and Virtual Care (WIHV) at Women’s College Hospital, where he is also a staff cardiologist. As Director of WIHV, Dr. Bhatia leads evaluation for Choosing Wisely Canada, a national initiative managed through the University of Toronto in collaboration with the CMA. He is an Assistant Professor at the University of Toronto and an adjunct scientist at the Institute for Clinical Evaluative Sciences. He has worked as a clinical and research fellow in cardiology at Massachusetts General Hospital and Harvard University. Dr. Bhatia received his medical degree and MBA at McGill University and his internal medicine and cardiology training in Toronto.

Dr. Noah Ivers (MD, PhD) is a scientist at WCRI and adjunct scientist at ICES. He is also a family physician at Women's College Hospital (WCH) and an Assistant Professor in the Department of Family and Community Medicine and at the Institute for Health Policy, Management and Evaluation at the University of Toronto. His research focuses on the use of data to drive decision-making in health care and draws on a foundation in clinical epidemiology and health services research. He received the Rising Star Award from the Canadian Institutes of Health Research-Institute of Health Sciences and Policy Research (CIHR-IHSPR) in 2013, a New Investigator award from CIHR, and a Clinician Scientist award from the Department of Family and Community Medicine at the University of Toronto.