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Cardiac Stress Imaging More Frequent in the US among Patients whose Physicians Bill for Procedures

By MedImaging International staff writers
Posted on 30 Nov 2011

In the United States, patients treated by physicians who billed for both technical (practice/equipment) and professional (supervision/ interpretation) elements of nuclear and echocardiographic stress imaging tests were more prone to undergo such tests after coronary revascularization compared with patients of physicians who did not charge for these services, according to a recent study.

The study’s findings were published in the November 9, 2011, issue of the Journal of the American Medical Association (JAMA). “Cardiac stress testing procedures performed in the office setting can enable more rapid, efficient diagnostic testing and use of these procedures has increased significantly during the past decade. However, physician ownership of imaging equipment also could potentially induce testing in more discretionary situations, because the capital outlay for equipment is high and these investments must be recouped via procedure-related “technical fees,” which cover associated equipment and practice costs. Similar concerns have been raised regarding whether physicians who bill for the professional fees covering test interpretation might more often refer their own patients for these tests than those who do not bill for these services. However, little is known about how these reimbursement incentives might affect the routine use of cardiac stress testing,” according to the authors.

The American College of Cardiology Foundation (ACCF; Rockville, MD, USA) has published appropriateness utilization criteria (AUC) to provide guidance to clinicians for appropriate testing. Current AUC guidelines do not recommend routine testing within two years for patients undergoing percutaneous coronary intervention (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries) or within five years for patients having coronary artery bypass graft (CABG) surgery, unless the need for stress testing is motivated by symptoms or events.

Bimal R. Shah, MD, MBA, from Duke University Medical Center (Durham, NC, USA, and colleagues assessed whether there was a link between patients undergoing cardiac stress imaging after coronary revascularization and the pattern of stress imaging billing of the physician practice providing their follow-up care. Using data from a US health insurance carrier, 17,847 patients were identified who between November 2004 and June 2007 had coronary revascularization and an index cardiac outpatient visit more than 90 days following the procedure. Based on overall billings, physicians were categorized into three classifications: physicians who routinely charged for technical and professional fees; physicians who regularly billed for professional fees only; and physicians who did not routinely bill for either service. Analytic models were used to evaluate the association between physician billing and use of stress testing, after adjusting for patient and other physician factors.

During the study period, the overall 30-day incidence of either nuclear stress testing or stress echocardiography testing associated with the index cardiac-related outpatient visit was 12.2%, with an overall incidence of 10.4% for nuclear stress testing and 1.8% for stress echocardiography. The incidence of nuclear stress testing among clinicians who billed for both technical and professional fees, professional-only fees, and neither fee for nuclear stress testing was 12.6%, 8.8%, and 5.0%, respectively. The stress echocardiography testing incidence among physicians who billed for both technical and professional fees, professional-only fees, and neither fee for stress echocardiography was 2.8%, 1.4%, and 0.4%, respectively.

Data analysis revealed that physicians who billed for technical and professional fees for nuclear stress testing and those who billed for professional fees only were more likely to perform nuclear stress tests following revascularization than those not billing (13.3% and 9.4% vs. 5.3%). Physicians who billed for technical and professional fees for stress echocardiography testing or professional fees only were more likely to perform stress echocardiography testing following revascularization than those not billing (3.1% and 1.5 percent vs. 0.5%).

The investigators reported that even though current ACCF AUC do not recommend regular use of early stress testing following coronary revascularization, they found that 12% of patients with a cardiac-related outpatient visit at least three months after revascularization underwent a stress test within 30 days of their visit. Moreover, up to one in 10 patients who were not classified as having symptoms at their outpatient visit still underwent stress testing.

“Our study highlights the need for application of the ACCF AUC in clinical practice and augments findings of other studies that have explicitly examined application of ACCF AUC for nuclear stress and stress echocardiography. The ACCF AUC provides guidance to clinicians regarding when to pursue cardiac stress testing to assist in narrowing variation in testing among clinicians and practices. Discretionary stress testing after revascularization has potential financial and clinical disadvantages for patients, including the costs of the tests, the exposure to ionizing radiation as well as potential down-stream costs, and consequences from following up false-positive test results,” the researchers concluded in their article. “These data suggest the need for broader application of AUC to minimize the possible influence of financial incentives on the decision to perform cardiac stress testing after revascularization.”

Related Links:
American College of Cardiology Foundation
Duke University Medical Center

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56 (540.97175598145): 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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

57 (!!!!! 1191.1392211914): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

58 (61.988830566406): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

59 (96.08268737793): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

60 (54.121017456055): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

61 (82.969665527344): 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 (473.97613525391): SELECT fid FROM jos_deeppockets WHERE id=294738232 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294738232 AND published='1' LIMIT 1

63 (291.10908508301): 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=214 ORDER BY `ordering`

64 (41.007995605469): select jos_twitters.link from jos_twitters where cat=10

65 (29.087066650391): select jos_facebook.link from jos_facebook where cat=10

66 (30.994415283203): select jos_google_plus.link from jos_google_plus where cat=10

67 (28.133392333984): select jos_linkedin.link from jos_linkedin where cat=10

68 (31.948089599609): SELECT fid FROM jos_deeppockets WHERE id=294738232 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294738232 AND published='1' LIMIT 1

69 (31.948089599609): 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=214 ORDER BY `ordering`

70 (231.98127746582): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

71 (214.0998840332): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

72 (40.054321289062): 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 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

74 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

75 (28.848648071289): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (25.98762512207): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (40.054321289062): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

88 (30.040740966797): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

89 (32.186508178711): 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 (46.014785766602): SELECT show_live FROM jos_com_show_setting LIMIT 1

91 (29.802322387695): SELECT show_live FROM jos_com_show_setting LIMIT 1

92 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (28.133392333984): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (27.179718017578): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (27.179718017578): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (27.894973754883): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (26.941299438477): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (154.97207641602): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

105 (72.002410888672): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

106 (50.067901611328): 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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

107 (50.067901611328): 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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

108 (73.909759521484): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

109 (48.160552978516): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

110 (51.021575927734): 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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

111 (591.99333190918): 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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

112 (516.17622375488): 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 (322.10350036621): 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 (92.029571533203): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

115 (90.837478637695): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

116 (70.095062255859): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

117 (52.213668823242): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

118 (108.00361633301): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

119 (51.021575927734): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

120 (114.91775512695): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

121 (55.074691772461): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

122 (288.00964355469): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

123 (!!!!! 19409.894943237): 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 (537.87231445312): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738232 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738232 AND type='deeppockets_item' AND published='1' LIMIT 1

125 (!!!!! 7035.9706878662): ( 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 (77.009201049805): ( 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 (36.954879760742): 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 (28.848648071289): 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 (50.783157348633): 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 (30.040740966797): 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 (310.18257141113): 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 (38.14697265625): 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 (30.994415283203): 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 (29.087066650391): 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 (502.8247833252): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

136 (337.12387084961): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

137 (199.0795135498): SELECT name FROM jos_deeppockets WHERE id=214

138 (32.186508178711): SELECT name FROM jos_deeppockets WHERE id=214

139 (533.8191986084): 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 '((;)|(^))214((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

140 (458.0020904541): 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 '((;)|(^))214((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

141 (70.095062255859): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

142 (46.014785766602): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

143 (!!!!! 7575.9887695312): TRUNCATE TABLE jos_trademed_module

144 (86.069107055664): 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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

145 (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_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=294738232 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

146 (813.96102905273): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

147 (49.829483032227): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

148 (69.856643676758): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

149 (54.121017456055): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

150 (!!!!! 1065.0157928467): 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 (71.048736572266): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

152 (54.836273193359): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

153 (43.153762817383): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294738232 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294738232 AND type='deeppockets_item' AND published='1' LIMIT 1

154 (461.10153198242): 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=214 or channel_id is null)

155 (42.200088500977): 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=214 or channel_id is null)

156 (41.961669921875): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

157 (!!!!! 1127.0046234131): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

158 (64.13459777832): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294738232 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294738232 AND published='1' LIMIT 1

159 (37.193298339844): select jos_twitters.link from jos_twitters where cat=10

160 (30.994415283203): select jos_facebook.link from jos_facebook where cat=10

161 (33.140182495117): select jos_google_plus.link from jos_google_plus where cat=10

162 (38.862228393555): select jos_linkedin.link from jos_linkedin where cat=10

163 (252.96211242676): update jos_bannersmanager_banner set impmade=impmade+1 where id in(14202,14203)

164 (!!!!! 1034.9750518799): insert into jos_banners_delta values (14202,'2025-06-24 00:51:11','216.73.216.120','view'),(14203,'2025-06-24 00:51:11','216.73.216.120','view')

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