Too Many Americans Get ‘Low Value’ Medical Tests

WEDNESDAY, Feb. 23 (HealthDay News) — When your cardiologist orders a test, do you stop to ask why you need it? Probably not, but maybe, according to a new report from the American Heart Association (AHA).

Too many Americans are getting heart tests and treatments that don’t do much good, and more needs to be done about it, the AHA says.

The issue of “low value” medical care is a longstanding one — with about half of Americans receiving at least one such test or procedure each year, the Heart Association notes.

The term refers to health services that are unlikely to benefit patients in any meaningful way, exposing them to potential harm and waste of money. It is estimated that low-value medical care accounts for about 30% of health care spending in the United States — or up to $101 billion a year.

In a new scientific statement, the AHA is drawing renewed attention to the issue, particularly when it comes to cardiac care.

Among the low-level tests and treatments are annual exercise tests for people who have had angioplasty or surgery to remove blocked arteries; echocardiograms to assess people who have passed out but have no signs or symptoms of heart problems; and coronary calcium tests for people already known to have heart disease.

“Clinicians and systems really strive to provide the best care for patients,” says Dr. Vinay Kini, president of the AHA Statement Writing Group.

But for a variety of reasons, he said, some low-value practices may become or remain commonplace.

As new technologies and treatments quickly become available, Kini said, health professionals need to figure out how best to use them. And some applications may prejudge the evidence.

Change ‘Best Practices’

There may be a practice that seemed the sensible way 15 years ago, Kini said, but the evidence gathered shows otherwise.

And once a practice is established, it can be difficult to call it back, said Dr. Richard Kovacs, medical director of the American College of Cardiology (ACC).

Individual physicians can rely on and stick to their personal experience and belief that a test or treatment will help patients. Or, Kovacs said, they may just not be aware of the evidence that a particular practice is actually of low value.

Then there’s the fear of being sued, he noted, which may prompt doctors to practice “defensive medicine” and order tests to make sure nothing was missed.

“And we have to be honest,” Kovacs said. “Some doctors do it for financial reasons.”

The ACC dates back to 2006 and has published “appropriate use criteria” for numerous cardiac tests and procedures, in an effort to limit low-value care.

“I think they have changed the practice and changed it for the better,” said Kovacs, who was not involved in the new report.

But there is still plenty of room for improvement, according to Kini.

An example is cardiac stress testing, in which people walk on a treadmill or pedal an exercise bike while checking their heart rate, blood pressure and breathing.

Research suggests that up to half of stress tests conducted in the United States are rated “rarely appropriate,” the AHA says. The problem with that isn’t just a waste of time and money: it can also lead to invasive testing that carries more risk and even more cost.

It’s not that heart tests are useless in and of themselves. They must be applied to the right patient, the AHA says.

For example, do coronary calcium testing. The non-invasive tests detect calcium deposits in the arteries and can be “high grade” when a patient is considered to be at “average” risk of heart attack. If the calcium score is high, it’s a good idea to start a cholesterol-lowering statin.

However, the test is of no value to someone with known blockages in the heart arteries: a statin would clearly be appropriate.

What can be done? Actions at different levels are needed, Kini said.

In general, the US health care system is designed to reward quantity — more tests, more treatments — versus quality. A payment system based on quality of care is the “way forward,” Kini said, although defining quality is complicated.

And one downside, he noted, is that those systems could ultimately penalize safety net hospitals, which serve low-income patients whose conditions — including poverty and unstable housing — can make their care much more complicated. It will thus be necessary to ensure that alternative payment systems do not exacerbate inequalities in health care.

What patients can do?

Patients also play a role, Kini and Kovacs said. In some cases, they demand tests or treatments that aren’t necessary, and their provider gives credit.

However, that does not mean that patients should remain silent. It’s the opposite, Kovacs said: If your doctor recommends a test or treatment, feel free to ask why and if there are alternatives.

“I would appreciate it if my patients say, ‘What are my options?'” Kovacs said.

And while costs are a huge problem for the health care system, they also matter for patients, Kini noted. With the rise of high-deductible insurance and other forms of “cost-sharing,” American patients bear a greater share of their medical bills.

That makes it even more important, Kini said, to make sure they get high-quality care.

The statement was published Feb. 22 in the AHA journal Circulation: Cardiovascular Quality and Outcomes.

More information

Choosing wisely has more information about heart tests and procedures.

SOURCES: Vinay Kini, MD, MSHP, assistant professor of medicine, Weill Cornell Medical College, New York City; Richard Kovacs, MD, medical director, American College of Cardiology, Washington, DC; Circulation: Cardiovascular Quality and Results, Feb 22, 2022, Online

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