Skipping Low-Value Cardiovascular Care Could Save Billions: AHA

The American Heart Association (AHA) is reminding physicians to avoid sending patients on for low-value tests and procedures that provide limited clinical benefit and may even result in harm.  

While various tests, scans, and treatments can help diagnose, screen, and care for patients with cardiovascular disease, some of them can be overused in certain settings, costing the healthcare system millions of dollars that could be spent elsewhere.  

“To put it in a broader perspective, it’s estimated that nearly half of all fee-for-service Medicare beneficiaries will receive at least one low-value healthcare service every year,” Vinay Kini, MD, MSHP (Weill Cornell Medical College, New York, NY), chair of the AHA scientific statement, told TCTMD. “That accounts for up to $100 billion annually. This is money that doesn’t necessarily contribute to improving the overall health of people in the US and money that could be potentially better spent on healthcare that is clearly beneficial to patients or other things that could improve population health.”  

In the statement, which was published last week in Circulation: Cardiovascular Quality and Outcomes, the AHA experts say that low-value care is easy to access, is potentially lucrative, and generally doesn’t put the patient at too much risk. Nonetheless, it’s far from benign.

Low-value care can trigger a treatment cascade, with tests begetting more tests, and also can uncover incidental findings, such as those that wouldn’t have harmed the patient, that will lead to further testing and follow-up. There is also the potential for hospital-acquired complications, such as infection, that may result from low-value tests and/or procedures.

It’s estimated that nearly half of all fee-for-service Medicare beneficiaries will receive at least one low-value healthcare service every year. Vinay Kini

Differentiating low-value from inappropriate care, Kini said the introduction of cost is the major factor, but emphasized that this can be defined in a lot of different ways. “It can be the cost to the patient, which could include out-of-pocket costs, time costs, and emotional and physical costs,” he said. “It could also include the cost to society. If someone is on Medicare, for example, it factors in how much society pays for a test or a treatment.”

Some examples of low-value care, according to the AHA, include the following:

• Serial high-sensitivity troponin testing in patients at low risk for cardiac ischemia
• Routine annual stress testing in patients after coronary revascularization
• Coronary artery calcium testing in patients with established atherosclerotic cardiovascular disease
• Echocardiography in patients presenting with syncope but no other signs, symptoms, or ECG evidence of cardiac disease
• PCI in patients with manageable symptoms who are considered low risk based on stress testing
• Dual-chamber implantable cardioverter-defibrillator (ICD) placement in patients with pacing indications

The group points out that previous meta-analyses have shown that nearly one in five echocardiograms and nearly half of all stress tests are rarely appropriate. These tests can then lead to more testing, such including invasive coronary angiography. PCI is still performed unnecessarily—approximately 10% to 15% are deemed rarely appropriate—and many ICDs implanted in patients are not based on the evidence, according to the AHA. Low-value care also includes medications, such as prescription of brand-name drugs over their cheaply available generic counterparts.

In terms of costs, it’s been previously estimated that low-value stress testing in stable CAD patients costs Medicare hundreds of millions of dollars each year, as does preoperative noninvasive testing. Similarly, low-value care following preoperative ECGs is estimated to cost Medicare another $35 million.

Value in Eye of Beholder

Andrew Foy, MD (Penn State Health, Hershey, PA), who wasn’t part of the AHA writing group, said the statement addresses many important issues with low-value cardiovascular care, but the key will be whether anything changes as a result.

Foy, who has previously been critical of unnecessary and overly-aggressive medical interventions, noted that while most physicians can agree on egregious examples of low-value care, such as those listed by AHA writing group, there is a relatively large “gray area” in between high- and low-value care where necessity is in the eye of the beholder. Differences in opinion surrounding the value of certain test or procedure can be the result of biases that are difficult to appreciate.

“I’m not talking about gross financial biases, but other ways in which self-interest might affect judgement and decision-making,” he said. “I do think a lot of this stuff is extremely subjective.” 

The goal of industry is to make money. Andrew Foy

The AHA recognizes that the causes of low-value care are complex, and list financial incentives, patient expectations, and local practice culture as some of the reasons for its proliferation. To address the issue, they propose a number of solutions at the patient, clinician, payer, and policy levels. At the patient and clinician level, Kini said there is a need for a “frank conversation” about the risks, benefits, and costs of any treatment, test, or procedure so that decisions are made with the patient preferences in mind.

From a payer and policymaker standpoint, instead of a fee-for-service model, payment should be tied to performance where portions of reimbursement are based on quality and efficiency measures.

“I’m of the opinion that’s a good transition to make, one away from fee-for-service towards value-based payments,” said Kini. “There are some caveats to that, too. Some value-based payments can worsen existing health disparities and inequities. Some can place undue burdens on clinicians and health systems. So that transition is a good thing, but it needs to be accompanied by measurement of the impact of these value-based payments and on any potential unintended consequences.”

Influence of Industry

In terms of why low-value care continues to exist in cardiovascular medicine, Foy said he believes that’s predominantly the result of industry.

“The goal of industry is to make money, and I think what I see in terms of what is being considered innovative isn’t really moving the needle very much at all,” Foy told TCTMD. “If we were to really internalize some of the broad-based concepts from the [AHA statement], we should really have the courage to call those things out.”

For example, he said, the US Food and Drug Administration recently granted an expanded indication for CardioMEMS pulmonary artery pressure monitor (Abbott) to include patients with NYHA class II heart failure on the basis of the GUIDE-HF trial, which failed to meet its primary endpoint, although a “pre-COVID-19” subanalysis suggested a benefit for the device. “Now it’s going to be adopted very quickly,” he said, despite the weak data. “I already sense the strong push from marketing and the hype that’s around it, but I haven’t really seen much in the way of formal pushback.”

Newer drugs, such as sacubitril/valsartan (Entresto; Novartis), also are promoted aggressively, even though the data supporting their use are not particularly impressive, said Foy.

For Foy, changes to health insurance plans where patients are footing some of the out-of-pocket costs isn’t necessarily a bad thing, because they can “clarify priorities.” When speaking with patients about which tests, procedures, and/or treatments to pursue, Foy stressed that it’s important to convey information about the risks and benefits in a way that’s understandable.

Finally, the concerns about low-value care also extend to consumer products not regulated by the FDA, such as smart watches and other devices designed to check for abnormal heart rhythms. These recordings can be misinterpreted and lead to unnecessary consultations with cardiologists and other specialists. While innovation in medical technology is important, driving a lot of advances that can have an impact in the lives of patients, Kini said there can be consequences of that relentless drive.

“Sometimes technology can outpace our understanding of how best to use it,” he said. “Certainly, when you’re talking about technology that isn’t necessarily regulated, or subject to the same level of scrutiny by large, randomized clinical trials, that potential to outpace our understanding is amplified. I think these technologies have a lot of promise, but we need to be cautious in applying them to everybody. It takes time to see where their real value might be.”