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Healthcare Costs Could Be Cut by More Appropriate Use of Cardiac Stress Imaging

By MedImaging International staff writers
Posted on 19 Oct 2014

In new research, investigators concluded that overuse of cardiac stress testing using advanced imaging technology has led to increasing healthcare costs in the United States and unnecessary radiation exposure to patients.

Researchers from the New York University Langone Medical Center (NYU; New York, NY, USA), in what is believed to be the first comprehensive examination of trends in cardiac stress testing utilizing imaging, also revealed that there are no significant racial or ethnic health disparities in its use. They also made US estimates of the cost of unnecessary cardiac stress testing with imaging and the health burden of this testing, in relation to cancer risk due to radiation exposure. The study’s findings were published October 7, 2014, in the journal Annals of Internal Medicine.

Cardiac stress testing, especially with imaging, has been at the forefront of debate about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure. Joseph Ladapo, MD, PhD, assistant professor in the departments of medicine and population health at NYU Langone, and the lead author of the study, and colleagues wanted to determine whether US trends in cardiac stress testing with imaging may be attributable to population shifts in demographics, risk factors, and provider characteristics, and to assess whether racial/ethnic discrepancies exist in physician decision making.

The investigators designed their study utilizing data from the US National Ambulatory Medical Care Survey (NAMCS) and US National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2010. Patients chosen for the study were adults without coronary heart disease who were referred for cardiac stress tests.

Between 1993–1995 and 2008–2010, the yearly number of ambulatory visits in the United States in which a cardiac stress test was prescribed or performed increased by more than 50%. Cardiac stress tests with imaging comprised a rising percentage of all of these tests—increasing from 59% in 1993–1995 to 87% in 2008–2010. At least 34.6% (one million tests) were probably inappropriate, the researchers concluded, with associated annual costs of USD 501 million and 491 future cases of cancer.

The authors also concluded that there was no evidence of a lower likelihood of black patients receiving a cardiac stress test with imaging (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than their white counterparts—although some slight evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]). The investigators concluded that the national growth in cardiac stress testing can be attributed mostly to population and provider characteristics, but the use of imaging cannot. Physician decision making about cardiac stress testing also does not result in racial/ethnic disparities in cardiovascular disease.

“Cardiac stress testing is an important clinical tool,” said Dr. Ladapo, “but we are over using imaging for reasons unrelated to clinical need. This is causing preventable harm and increasing healthcare costs. “Reducing unnecessary testing also will concomitantly reduce the incidence of radiation related cancer. We estimate that about 500 people get cancer each year in the US from radiation received during a cardiac stress test when, in fact, they most probably didn’t need any radiological imaging in the first place. While this number might seem relatively small, we must remember that “first, do no harm” is one of the guiding principles in medicine.”

As to what can be done to reduce unnecessary cardiac stress testing with imaging, “More efforts, such as clinical decision support, are needed to reduce unnecessary cardiac stress testing,” Dr. Ladapo reported, suggesting greater use of stress testing without radiological imaging, such as regular exercise treadmill tests or stress testing with ultrasound imaging as opposed to CT [computed tomography] imaging.

As to why specific racial and ethnic minorities have poorer rates of treatment for cardiovascular disease and generally have poorer cardiovascular health outcomes compared to white patients, Dr. Ladapo concluded that no one has really explored whether there could be disparities in cardiac stress testing, which is a mainstay of diagnosing patients with heart disease in this country. “If we know that one minority group has a higher incidence of poorer outcomes from heart disease, perhaps we need to examine if they would benefit from more appropriate use of cardiac stress testing,” he proposed. “Perhaps one contributing reason they have poorer outcomes is because we are not testing them appropriately.”

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59 (519.0372467041): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

60 (524.99771118164): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

61 (!!!!! 5590.9156799316): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

62 (!!!!! 1046.895980835): SELECT fid FROM jos_deeppockets WHERE id=294755211 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294755211 AND published='1' LIMIT 1

63 (!!!!! 10045.051574707): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=211 ORDER BY `ordering`

64 (133.99124145508): select jos_twitters.link from jos_twitters where cat=10

65 (!!!!! 4132.9860687256): select jos_facebook.link from jos_facebook where cat=10

66 (!!!!! 5290.0314331055): select jos_google_plus.link from jos_google_plus where cat=10

67 (185.96649169922): select jos_linkedin.link from jos_linkedin where cat=10

68 (66.995620727539): SELECT fid FROM jos_deeppockets WHERE id=294755211 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294755211 AND published='1' LIMIT 1

69 (534.0576171875): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=211 ORDER BY `ordering`

70 (!!!!! 2820.0149536133): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

71 (!!!!! 6121.8738555908): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (720.02410888672): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

73 (69.856643676758): SELECT show_live FROM jos_com_show_setting LIMIT 1

74 (46.968460083008): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (44.107437133789): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (38.14697265625): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (34.809112548828): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (39.100646972656): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (44.107437133789): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (29.802322387695): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (56.982040405273): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (56.028366088867): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

88 (30.994415283203): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (34.093856811523): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

90 (65.088272094727): SELECT show_live FROM jos_com_show_setting LIMIT 1

91 (32.901763916016): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (41.961669921875): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (50.067901611328): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (49.114227294922): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (29.087066650391): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (102.04315185547): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

105 (66.995620727539): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

106 (56.982040405273): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294755211 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

107 (59.843063354492): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294755211 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (!!!!! 1118.8983917236): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

109 (88.930130004883): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

110 (70.095062255859): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294755211 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

111 (!!!!! 5491.9719696045): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294755211 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (761.98577880859): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

113 (576.01928710938): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

114 (215.05355834961): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

115 (107.0499420166): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

116 (119.92454528809): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

117 (75.817108154297): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

118 (133.99124145508): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

119 (58.174133300781): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

120 (77.962875366211): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

121 (55.074691772461): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

122 (389.09912109375): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

123 (!!!!! 143142.93861389): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

124 (!!!!! 3666.877746582): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294755211 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294755211 AND type='deeppockets_item' AND published='1' LIMIT 1

125 (92.983245849609): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

126 (40.054321289062): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

127 (218.86825561523): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

128 (50.067901611328): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

129 (41.961669921875): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

130 (29.802322387695): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

131 (61.988830566406): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

132 (46.014785766602): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

133 (594.8543548584): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

134 (33.855438232422): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

135 (401.02005004883): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

136 (477.07557678223): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (204.08630371094): SELECT name FROM jos_deeppockets WHERE id=211

138 (47.922134399414): SELECT name FROM jos_deeppockets WHERE id=211

139 (688.07601928711): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

140 (!!!!! 3017.9023742676): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

141 (!!!!! 5249.0234375): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

142 (!!!!! 11898.040771484): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

143 (!!!!! 4178.0471801758): TRUNCATE TABLE jos_trademed_module

144 (!!!!! 1617.9084777832): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294755211 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

145 (82.969665527344): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294755211 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (454.18739318848): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

147 (51.975250244141): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (68.902969360352): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

149 (89.883804321289): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

150 (!!!!! 1066.9231414795): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

151 (79.870223999023): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

152 (56.028366088867): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

153 (49.114227294922): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294755211 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294755211 AND type='deeppockets_item' AND published='1' LIMIT 1

154 (433.92181396484): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=211 or channel_id is null)

155 (40.054321289062): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=211 or channel_id is null)

156 (55.074691772461): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

157 (!!!!! 4917.1447753906): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

158 (!!!!! 4045.0096130371): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294755211 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294755211 AND published='1' LIMIT 1

159 (347.13745117188): select jos_twitters.link from jos_twitters where cat=10

160 (46.968460083008): select jos_facebook.link from jos_facebook where cat=10

161 (40.054321289062): select jos_google_plus.link from jos_google_plus where cat=10

162 (31.948089599609): select jos_linkedin.link from jos_linkedin where cat=10

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