Too Many Americans Are Getting ‘Low-Value’ Medical Tests

WEDNESDAY, February 23, 2022 (Health Day News). When your cardiologist orders a test, do you stop to ask why you need it? Probably not, but according to a new report from the American Heart Association (AHA), it might be. The AHA says too many Americans are getting heart tests and treatments that don’t work, and something needs to be done about it.

The Heart Association notes that the problem of “affordable” care has been around for a long time, with about half of Americans undergoing at least one such test or procedure each year.

The term refers to medical services that are unlikely to provide significant benefit to patients, exposing them to potential harm and waste of money. It is estimated that affordable healthcare accounts for about 30% of health care spending in the United States, or up to $101 billion a year.

In the new scientific statement, the AHA is once again drawing attention to this issue, especially when it comes to cardiac care.

Among the low-value tests and treatments, there are annual exercise stress tests for people who have undergone angioplasty or surgery to clear clogged arteries; echocardiograms to evaluate people who have passed out but have no signs or symptoms of heart problems; as well as coronary calcium tests for people already known to have heart disease.

“Physicians and systems are really committed to providing the best possible care for patients,” said Dr. Vinay Kini, chairman of the AHA’s claim writing team.

But for various reasons, he said, some practices of little value can become or remain commonplace.

As new technologies and treatments quickly become available, healthcare professionals need to figure out how best to use them, Keaney said. And some uses may be ahead of the evidence.

Changing “best practices”

There may be practices that seemed wise 15 years ago, Keaney said, but evidence collected since then suggests otherwise.

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

Individual doctors may rely on their personal experience and belief that a test or treatment works for patients and stick to it. Or, according to Kovacs, they may simply not be aware of the evidence that the practice is actually of little value.

In addition, he noted that there is a fear of prosecution, which may encourage doctors to practice “defensive medicine” and order tests to make sure nothing is overlooked.

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

Going back to 2006, the ACC published “appropriate use criteria” for numerous cardiac tests and procedures to limit low-cost care.

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

But according to Keaney, there’s still a lot of room for improvement.

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

Studies show that up to half of stress tests conducted in the United States will be rated as “rarely appropriate,” the AHA said. The problem is not only wasted time and money: it can also lead to invasive testing, which comes with more risk and even more expense.

It’s not that heart tests are useless on their own. According to the AHA, they need to be applied to the right patient.

Take, for example, coronary calcium tests. Non-invasive tests detect calcium deposits in the arteries and can be “high” when the patient is considered to be at “intermediate” risk for a heart attack. If the calcium level is high, then it is recommended to start lowering cholesterol levels statins medicine.

However, the test is useless for a person with known blockages in the heart arteries: a statin would definitely work.

What can be done? According to Keaney, action is needed at different levels.

Broadly speaking, the US healthcare system is designed to encourage quantity—more tests, more treatments—instead of quality. A quality-based payment system is “the way forward,” Keaney said, although the quality is difficult to define.

And the downside, he noted, is that these systems can end up penalizing social care hospitals that serve low-income patients whose circumstances, including poverty and precarious housing, can make caring for them much more difficult. Thus, it will be necessary to ensure that alternative payment systems do not exacerbate health inequalities.

What Patients Can Do

Patients also play a role, Keaney and Kovacs say. In some cases, they require tests or treatments that are not necessary, and their provider concedes.

However, this does not mean that patients should be silent. On the contrary, Kovacs said: If your doctor recommends a test or treatment, don’t hesitate to ask why and if there are alternatives.

“I’d love it if my patients asked, ‘What are my options?'” Kovacs said.

And while costs are a huge problem for the healthcare system, they are also important for patients, Keaney said. With the advent of high-deductible insurance plans and other forms of “cost-sharing,” US patients bear a large share of their medical bills.

This makes it even more important to ensure they receive valuable assistance, Keaney said.

The statement was published on Feb 22 in AHA magazine. Circulation: Cardiovascular Quality and Outcomes.

More information

Wisely’s Choice has more information on heart tests and procedures.

SOURCES: Vinay Kini, MD, MSHP, Associate Professor, Medicine, Weill Cornell Medical College, New York; Richard Kovacs, MD, Chief Medical Officer, American College of Cardiology, Washington, DC; Circulation: Cardiovascular Quality and OutcomesFebruary 22, 2022, online

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