Use of non-indicated cardiac testing in low-risk patients: Choosing Wisely

In 2011, the American Board of Internal Medicine Foundation created the Choosing Wisely initiative, which encourages physicians to be responsible stewards of finite healthcare resources.1 Through this programme, specialty societies have created lists of “Five Things Physicians and Patients Should Question”. Cardiac testing in low-risk patients appears on the Choosing Wisely lists of six specialty societies (see online supplementary table S1). A challenge in studying potential waste or creating incentives for improving healthcare efficiency is the scarcity of accepted definitions of low-value or potentially harmful care. To date, Choosing Wisely recommendations have not been translated into claims-based algorithms for measurement purposes and thus neither the prevalence of these services nor the associated spending has been estimated at a population level. Using Medicare administrative data from 2006 to 2011, we estimated the proportion of low-risk Medicare beneficiaries receiving non-invasive cardiac screening tests without a clear, pertinent symptomatic indication, as well as the regional variation in and spending associated with these tests. For comparison and as a validation of our patient risk assignment, we measured cardiac testing in beneficiaries with or at high risk for cardiac disease. Using the Medicare 40% denominator file, we identified all fee-for-service Medicare beneficiaries enrolled in Medicare Parts A, B and D (inpatient, outpatient and prescription coverage), 2006–2011, and created six annual enrolment cohorts (see online supplementary table S1 for an expanded version of methods). Each beneficiary was assigned a cardiovascular disease risk status (low or high) based on records in Medicare Carrier, Outpatient, MedPAR, Hospice and Prescription Drug Event files using a combination of International Classification of Disease codes and drug ingredient codes. For each annual enrolment cohort, beneficiaries with no evidence of significant cardiovascular disease or cardiovascular risk were deemed low-risk, and the remaining beneficiaries were deemed high-risk for cardiovascular disease or cardiovascular events. …