Highlights
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Low-value health care is common and costly to individuals and society, accounting for up to 30% (up to $101 billion annually) of health care spending in the U.S. The current scope and impact of care low-value cardiovascular outcomes are reviewed in a new scientific statement from the American Heart Association, published in the Association’s journal Circulation: Cardiovascular Quality and Outcomes.
The statement proposes solutions to reduce low-value cardiovascular care and areas for future research priorities. An American Heart Association Scientific Statement is an expert analysis of current research and can inform future guidelines.
Low-value health care is a medical test, treatment, or procedure that does not provide a "net benefit" by weighing health benefits (such as symptom relief) against the potential to cause harm (general risks, including possible complications); the cost of the test, procedure or treatment; and whether similar benefits may be available in alternative forms of care.
Nearly 50% of patients in the US will receive at least one low-value test or procedure per year.
Previous research and a report from the National Academy of Medicine estimate that approximately $76-101 billion of annual health care spending in the U.S. may be considered unnecessary or wasteful. Cardiovascular care may be prone to a high frequency of low-value tests and procedures.
“Cardiovascular disease is common and can occur suddenly, like a heart attack or an abnormal heart rhythm,” said Vinay Kini, MD, MSHP, chair of the statement writing group and assistant professor of medicine at Weill Cornell Medical College in New York. . “Our desire to be vigilant in the treatment and prevention of cardiovascular diseases can sometimes lead to the use of tests and procedures in which the benefits to patients may be uncertain. “This can impose burdens on patients, in the form of increased risk of physical harm from the low-value procedure or potential complications, as well as follow-up care and out-of-pocket financial costs.”
Screening and diagnostic tests remain valuable and informative in guiding the treatment of people with established cardiovascular disease. However, overuse of some cardiac tests may occur as they are widely available, may be financially beneficial to the healthcare facility, and are generally low risk to patients.
Studies have found that up to 1 in 5 echocardiograms and up to half of all stress tests performed in the US can be rated as rarely appropriate, based on established guidelines for their use. An example of an inappropriate stress test is when a patient who has had stent or bypass surgery has an annual stress test despite feeling well and not having any symptoms that warrant the test. These tests can lead to more invasive tests that can also have higher risks for patients, as well as increased costs for the patient and the healthcare system, as well as increased stress or anxiety for patients.
Unnecessary tests and procedures also pose additional risks to patients’ health, such as radiation exposure and hospital-acquired infections. In the US, up to 15% of percutaneous coronary interventions (PCI), in which a stent is placed in the blocked artery, are classified as rarely appropriate . “Some patients who undergo these procedures may still benefit from being treated with medications,” Kini said.
“The treatment and management of cardiovascular diseases is a rapidly changing field of medicine, where new and innovative tests and treatments are always being developed. “Medical advances are important, however, sometimes the rapid pace of innovation outpaces our understanding of how to best use new tests and treatments.”
The rapidly expanding consumer device industry is another factor driving up costs with little benefit to patients. Some of the devices that monitor heart rate and physical activity also evaluate heart rhythms, but more than a third of these recordings can be subject to misinterpretation by doctors and patients.
The writing group conducted a comprehensive review of the medical and economic literature on low-value healthcare published since 2000 to describe the extent of low-value care in the US.
Low-value healthcare is a complex problem. Achieving meaningful reductions in low-value cardiovascular care requires a multidisciplinary approach that includes ongoing research, implementation, evaluation, and adjustment, while ensuring equitable access to care.
“Each approach has advantages and disadvantages,” Kini said. “For example, prior authorization places a large burden on healthcare professionals to obtain insurance approval for tests and treatments. Prior authorization and some value-based payment models may unintentionally worsen existing racial and ethnic disparities in health care. A one-size-fits-all approach to reducing low-value care is unlikely to be successful; rather, it is critical to act through multiple perspectives and frequently measure impacts and potential unintended consequences.”
Policies and interventions to reduce low-value care should be designed with the needs of people in historically under-resourced communities and people from diverse racial and ethnic groups in mind.
These interventions should be rigorously studied after implementation to evaluate their effectiveness and identify potential unintended consequences. Additionally, research is needed on novel approaches to reducing low-value care, such as ways to help patients and health care professionals discuss the value of tests and treatments being considered and evaluate the effectiveness of new delivery models. payments designed to improve the value of health care.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association Council on Care Quality and Outcomes Research. The American Heart Association’s scientific statements promote greater awareness of cardiovascular disease and stroke and help facilitate informed health care decisions.
Scientific statements describe what is currently known about a topic and what areas need additional research. While scientific statements inform guideline development, they do not make treatment recommendations. The American Heart Association guidelines provide the Association’s official clinical practice recommendations.
Co-authors are Vice President William B. Borden, MD, FAHA; Khadijah Breathett, MD, MS, FAHA; Peter W. Groeneveld, MD, MS, FAHA; P. Michael Ho, M.D., Ph.D., FAHA; Brahmajee K. Nallamothu, MD, MPH, FAHA; Pamela N. Peterson, MD, MSPH, FAHA; Pam Rush, M.S.; Tracy Y. Wang, MD, MHS, M.Sc., FAHA; and Emily P. Zeitler, MD, MHS Author disclosures appear in the manuscript.
