Stress Testing More Likely Among Physicians Who Bill for Such Services

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Patients are more likely to be sent for nuclear stress testing and stress echocardiography after coronary revascularization if they are treated by a physician who bills for such testing in their office, according to a study published in the November 9, 2011, issue of the Journal of the American Medical Association.

Bimal R. Shah, MD, of Duke University Medical Center (Durham, NC), and colleagues conducted a large study to determine if there was an association between the frequency of recommendations of these follow-up tests and the billing of the physician practice recommending the care. The data for the study came from 17,847 patients who had undergone coronary revascularization and subsequently had a cardiac outpatient visit more than 90 days postprocedure.

Physicians were grouped into 3 categories:

• Those who billed for technical fees, which included equipment, and professional fees, such as interpretation of results
• Those who billed for professional fees only
• Those who billed for neither

Variations in Referrals Captured

Overall, the 30-day incidence of either test was 12.2%, with 10.4% comprising nuclear stress tests and 1.8% stress echocardiography. For both nuclear stress testing and stress echocardiography, physicians who billed for both technical and professional fees had the most frequent patient-testing incidence compared with the other groups (table 1).

Table 1. Cumulative Incidence of Testing by Physician Billing Category

In multivariable analysis, patients treated by physicians who billed for technical and professional fees had adjusted odds ratios of 2.3 for nuclear stress testing and 12.8 for stress echocardiography compared with patients whose physicians billed for neither (P < 0.001 for both). Patients treated by physicians who billed for professional fees only had adjusted odds ratios of 1.6 for nuclear stress testing and 7.1 for stress echocardiography compared with physicians who did not bill for such testing (P < 0.001 for both).

Although stress testing was more common overall in symptomatic patients, up to 1 in 10 patients who were not coded as having symptoms at their outpatient visit still underwent stress testing.

Findings Not in Line with Current Recommendations

American College of Cardiology Foundation guidelines do not recommend routine stress testing within 2 years of PCI or within 5 years of CABG surgery. In light of this, Dr. Shah and colleagues say their results highlight “the need for application of the ACCF [appropriate utilization criteria] in clinical practice.”

However, in a telephone interview with TCTMD, J. Jeffrey Marshall, MD, of Northeast Georgia Medical Center (Gainesville, GA), said while it is important to follow guidelines, “the caveat from this study is that the stress echo appropriateness criteria did not come out until all of these patients had been cared for.”

Furthermore, any guidelines that exist are just that, a guideline, added Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY).

“There is going to be a baseline level of what I would consider appropriate testing, even after revascularization that may be going against what the guidelines recommend,” he said in a telephone interview with TCTMD.

In addition, there are definitely some benefits to in-office testing, Dr. Kirtane explained.

“I work in an academic center and I often say that we have to reschedule the patient and ask them to come back on a different day. Patients are surprised because they expect that they were going to be seen [and] get it all done at the same time,” Dr. Kirtane said. “In terms of in-office testing, it is advantageous to the patient because they are familiar with the circumstances, they know their physicians and it is convenient.”

Study Design Limits Conclusions

Drs. Marshall and Kirtane also pointed out that the study has limitations, including the fact that it is based on a chart review and lacks any clinical information on the individual patients, making it difficult to infer reasons for the referrals.

Another issue is the potential for selective referral bias. In an editorial that accompanied the study, Brent K. Hollenbeck, MD, MS, and Brahmajee K. Nallamothu, MD, MPH, of the University of Michigan (Ann Arbor, MI), write that it is “highly plausible, if not likely, that patients who were thought to be in need of cardiac stress imaging would be preferentially referred to physicians who perform the service.”

A majority of the data used in the study was from cardiologist referrals, they note.

“Even though these results may seem provocative, I am sure there is more than meets the eye,” Dr. Marshall said. “The real question would be why patients were going to the cardiologist. We don’t really know anything about these patients.”

In the end, both Drs. Marshall and Kirtane agreed that the take-away message is that physicians should use caution and avoid bias when recommending imaging studies.

“We all need to be conscience about when and why we use tests that include radiation that can be harmful to our patients,” Dr. Marshall said. “All cardiologists need to do the right thing for the patient. We need to make sure that there are no biases involved.”

Dr. Kirtane added, “Every clinician ought to reassess the indication for any type of testing on an individualized basis. We would hope that financial issues should not be a reason why a physician would be ordering a test.”

 

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Sources:
1. Shah BR, Cowper PA, O’Brien SM, et al. Association between physician billing and cardiac stress testing patterns following coronary revascularization. JAMA. 2011;306:1993-2000.

2. Hollenbeck BK, Nallamothu BK. Financial incentives and the art of payment reform. JAMA. 2011;306:2028-2030.

 

 

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