Health Policy in Cardiovascular Medicine
Overuse of Cardiovascular Services
Evidence, Causes, and Opportunities for Reform
Xiaoyan Huang, MD, MHCM; Meredith B. Rosenthal, PhD
C
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ardiovascular disease is the leading cause of death in the
United States and constitutes 17% of overall national
health expenditures,1 with noninvasive testing contributing
much of the cost growth in recent years.2,3 Cardiovascular
medicine has long been at the forefront of evidence-based
practice, with arguably the longest-standing and most comprehensive array of efforts to measure risk factors and outcomes,
to analyze the clinical effectiveness and cost-effectiveness of
treatment options, and to formulate practice recommendations.4,5 Professional societies for cardiovascular medicine
have established health policy statements,6 national databases
on quality,7 clinical guidelines,8 and appropriate use criteria9
(AUC) for high-cost cardiovascular services (Table 1). More
recently, the profession has taken steps to right-size cardiovascular services by defining the problem of overuse and underuse and working to shape clinical and policy interventions that
improve quality and access and reduce unnecessary cost.10 For
example, the American College of Cardiology Wisconsin and
Florida chapters recently received a $15.8 million Centers for
Medicare & Medicaid Innovation grant to pilot a comprehensive cardiovascular program to improve quality and to reduce
cost of cardiovascular care through better data transparency,
patient engagement, and shared decision making (SDM).
Despite efforts to improve the value of cardiovascular
care, there is a concern that significant overuse of cardiovascular services persists in the United States. The published
evidence of overuse is necessarily incomplete for 2 key reasons. First, for many tests and treatments, there is a lack of
agreement on the basic definition of overuse. The Institute
of Medicine originally defined overuse as occurring when “a
health care service is provided under circumstances in which
its potential for harm exceeds the possible benefit”.11 Others
have since expanded the notion of overuse to describe services that maybe unscientific, redundant, excessive, duplicative, unnecessary, or harmful, leading to the concern that the
vague conceptual definition of overuse has likely contributed
to the lack of specific measures of overuse and initiatives to
address overuse.12 An alternative, the economist’s definition of
overuse, relates to whether the service in question has lower
benefits than its economic costs (ie, the opportunity cost of
the resources used to produce it). Second, clinical notions
of overuse almost always require consideration of bedside
nuance that can be obtained only from rich clinical databases,
which are often unavailable for research. It is thus not surprising to discover that the issue of overuse, despite its economic
and policy importance, remains understudied. A literature
review of >100 000 articles over 2 decades only yielded 172
articles that addressed the issue of overuse in health care in general.13 Of these, the most commonly studied services highlight
3 cardiovascular procedures: coronary angiography, coronary
artery bypass grafting (CABG), and carotid endarterectomy.
To reduce overuse, it is therefore necessary to establish sound
measures that reliably identify overuse, evaluate its clinical
and economic impact, and identify the causes and opportunities for reform and implement effective interventions.
In this article, we review what is known about the overuse of cardiovascular services based on specific definitions
(Table 2), describe major causal influences, and identify
emerging efforts to address overuse.
Evidence of Overuse
The most commonly used standard to identify overuse of cardiovascular services is the RAND appropriateness method.27
Over the last 9 years, the American College of Cardiology and
American Heart Association have developed 13 AUC documents on imaging, diagnosis, and treatment for cardiovascular
disease.28 These AUC documents have been valuable as serving as standards for program accreditation of echocardiography, nuclear imaging or cardiac catheterization laboratories,
and pay-for-performance contracts from payers in an effort to
measure overuse. Applying AUC for percutaneous coronary
intervention (PCI)29 in large clinical databases14-15 showed
that 12% to 19% of elective PCIs performed were found to be
of inappropriate indication and another 20% to 38% were of
uncertain indication. Revascularization in patients with uncertain or inappropriate indications was shown not to result in an
improvement in clinical outcomes such as subsequent death
or acute coronary syndrome. When AUC were applied for
nuclear myocardial perfusion imaging, the rate of inappropriate studies was found to range from 11% to 23%.16 Thirteen
percent to 30% of stress echocardiography has been shown to
be inappropriate, depending on whether the studies were done
in the inpatient or outpatient setting.17-18 Evidence of cardiac
stress testing overuse has been shown with significant temporal growth and a shift toward stress test with imaging. Using
data from the National Ambulatory Medical Care Survey and
From Providence Heart Clinic, Portland, OR (X.H.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
(M.B.R.).
Correspondence to Xiaoyan Huang, MD, MHCM, Providence Heart Clinic, 1111 NE 99th Ave, Ste 201, Portland, OR 97220.
E-mail [email protected]
(Circulation. 2015;132:205-214. DOI: 10.1161/CIRCULATIONAHA.114.012668.)
© 2015 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.114.012668
205
206 Circulation July 21, 2015
Table 1. Summary of Initiatives to Identify and Reduce Overuse in Cardiovascular Medicine
Initiative
Description
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AUC
Jointly developed by ACC Foundation AUC Task Force since 2005 to promote evidence-based, effective use of cardiovascular
technology
Based on RAND appropriateness methodology
Appropriateness is defined by weighing clinical benefit against risks, downstream procedures, and follow-up care
Can be accessed at www.cardiosource.org
Clinical guidelines
Jointly developed by ACC/AHA Task Force on Practice Guidelines around discrete clinical conditions since 1980
Expert analysis of evidence of benefit and harm for existing procedures and therapy to optimize patient outcome, to improve
quality, and to control cost
Can be accessed at www.cardiosource.org
Performance measures
Developed by the ACC/AHA Task Force on Performance Measures to establish discrete and composite performance
measurement standards since 2005
The performance measures are evidence based and focus on the process, outcome, composite, and efficiency of care
Can be accessed at www.cardiosource.org
Get With The Guidelines
A suite of in-hospital programs developed by the AHA to promote guideline adherence for common clinical conditions
Includes evidence-based guidelines, clinical tools, and resources for providers; patient educational resources; hospital
certification program; clinical data registry; and performance feedback for continued quality improvement
Can be accessed at www.heart.org
National Cardiovascular Data Registry
Developed by the ACC in 1997 as a quality data repository for acute and outpatient cardiovascular care and cardiovascular
procedures
Used to collect clinical and outcomes data, to benchmark performance, to identify quality gaps for continued quality
improvement, and to measure appropriate use of cardiovascular procedures
Can be accessed at www.ncdr.com
Choosing Wisely
An American Board of Internal Medicine Foundation initiative since 2012 to engage providers and patients in conversations to
ensure that the right care is delivered at the right time
>60 Specialty societies have identified 5 low-value services to promote care through better diagnostic and treatment choices
to reduce risk and waste
Consumer Reports is working with providers to help patients avoid potentially harmful and unnecessary care
Can be accessed at www.choosingwisely.org
Health policy statements
Overseen by the ACC Clinical Quality Committee since 1992 to promote or advocate the ACC position, to be informational in
nature, and to offer guidance of the ACC stance on pressing health policy issues;
Review current evidence around policy issues such as overuse, underuse, and misuse of services
Reconcile conceptual framework with clinical efficacy and economic efficiency of care
Provide overarching policy recommendations
Can be accessed at www.cardiosource.org
ACC indicates American College of Cardiology; AHA, American Heart Association; and AUC, appropriate use criteria.
National Hospital Ambulatory Medical Care Survey, Ladapo
et al24 recently found 34.6% of cardiac stress tests with imaging to be probably inappropriate, with associated annual costs
and harms of $501 million and 491 future cases of cancer. In
this study, clinical survey data from the National Ambulatory
Medical Care Survey and National Hospital Ambulatory
Medical Care Survey, including patient cardiac risk profile,
clinical symptoms, and physician diagnosis information, were
used to designate appropriateness of testing. The economic
and health impacts of potential overuse were estimated from
average national Medicare reimbursement and a previous
study of the effect of ionizing radiation.
These and other AUC documents have been widely
accepted as the gold standard to evaluate for appropriateness
of use, providing evidence of underuse and overuse. However,
it is important to recognize that the appropriateness method
was not intended for practice or physician profiling; the clinical scenarios described in these documents are by no means
exhaustive to capture the myriad case-specific clinical details
and exceptions in real-world practice. The limitation of AUC
for profiling overuse is underscored by the substantial plurality of cases that are classified as uncertain. More recently, the
terminology for AUC has shifted from “appropriate, uncertain,
or inappropriate” criteria to “appropriate, maybe appropriate,
or rarely appropriate.”
The second major category of overuse evidence comes
from examination of the deviation of clinical practice from
published guidelines or clinical trial results. For example,
the 2007 American College of Cardiology/American Heart
Association guidelines on perioperative evaluation for
patients undergoing noncardiovascular surgery recommend
that patients without existing cardiac conditions or risk factors should not undergo cardiac stress testing before elective noncardiac, nonvascular surgery.30 However, a Medicare
inpatient claims analysis showed that 3.75% of such patients
received nuclear stress testing, an expensive imaging test
with significant radiation, cost, and potential for a downstream invasive procedure.19 In this analysis, there was a significant temporal trend of increase of overuse, and hospital
size and high Medicare use region were also associated with
higher use, confirming the theory of supply-induced demand
described by the Dartmouth Atlas researchers nearly 2
decades ago.31 Likewise, non–evidence-based use of implantable cardioverter-defibrillators has been shown to have significant geographic variation and persistent overuse despite
the publication of clinical guidelines.20
Huang and Rosenthal Reducing Overuse in Cardiovascular Medicine 207
Table 2. Examples of Overuse in Cardiovascular Disease by Categories of Evidence
Categories of Evidence for Overuse
Examples
Chan et al (2011) and Ko et al (2012): 12%–19% of elective PCIs performed were found to be of inappropriate
indication, and another 20%–38% were of uncertain indication.
Gibbons and Miller16 (2013): 11%–23% of nuclear myocardial perfusion imaging tests done were found to be
inappropriate.
Bhatia et al17 (2013) and Willens et al18 (2013): 13%–30% of stress echocardiography studies were shown to be of
inappropriate indication.
Use deviating from clinical guidelines
Scheffield et al19 (2013): 3.75% patients without existing cardiac conditions or risk factors underwent cardiac stress
testing before elective noncardiac, nonvascular surgery against ACC/AHA practice guidelines.
Al-Khatib et al20 (2011): Non–evidence-based ICD implantations in the US.
Indirect evidence of overuse
Wennberg and Birkmeyer21 (1999): The Dartmouth Atlas of Cardiovascular Health Care showed unwarranted geographic
variation of cardiovascular procedure use: >10-fold imaging stress test, 8.5-fold for echocardiography, 8-fold for PCI, and
3-fold for CABG.
Chen et al22 (2011) and Huffman and van Geertruyden23 (2011): Very low downstream coronary angiography and
revascularization after stress myocardial perfusion imaging and stress echocardiography suggest very low pretest
likelihood of disease in patient selection and potential overuse of noninvasive stress testing.
Ladapo et al24 (2014): National survey data indicated significant trend of growth in cardiac stress testing with imaging;
34.6% of testing was found to be probably inappropriate based on patient risk profile, presenting symptoms, and visit
diagnosis, with associated annual costs estimated to be $501 million.
Evidence of overuse based on
recommendations from the Choosing
Wisely Campaign
Schwartz et al25 (2014): Applying claims-based measures of 26 low-value care showed that 25%–42% of beneficiaries
are affected by low-value care.
Colla et al26 (2014): Overall 13% of Medicare low-risk patients received nonindicated cardiac testing, including ECGs
(12.4%), stress tests (0.3%), and echocardiograms (0.25%).
15
ACC indicates American College of Cardiology; AHA, American Heart Association; AUC appropriate use criteria; CABG, coronary artery bypass graft; ICD, implantable
cardioverter-defibrillator; and PCI, percutaneous coronary intervention.
Besides inappropriate use of diagnostic tests and interventions, other indirect evidence also exists to suggest overuse of cardiovascular services. An analysis of a large private
insurance company database showed very low downstream
coronary angiography and revascularization after stress
myocardial perfusion imaging and stress echocardiography,
suggesting very low pretest likelihood of disease in patient
selection and implying potential overuse of noninvasive stress
testing.22-23 Additionally, the >10-fold regional variation for
imaging stress test use, 8.5-fold variation for echocardiography, 8-fold variation for PCI, and 3-fold variation for CABG
shown in The Dartmouth Atlas of Cardiovascular Health
Care21 is also felt to be reflective of unwarranted variation and
suggest potential overuse of supply-sensitive care (Figure).
130.0
Rates of Imaging Stress Testing
per 1,000 Medicare Enrollees
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Use deemed uncertain or inappropriate
based on published AUC
14
110.0
90.0
70.0
50.0
30.0
10.0
Figure. Rates of imaging stress testing among hospital referral
regions (1996). Rates of imaging stress testing ranged from ≈10
per 1000 enrollees to almost 120 after adjustment for differences
in population age, sex, and race. Each point represents 1 of the
306 hospital referral regions in the United States. Reprinted from
The Dartmouth Atlas of Cardiovascular Healthcare with permission from the publisher.21
On the other hand, cross-national studies of cardiac service
use show that overuse is not linked to overall service volume,32
suggesting that blunt policies to simply restrict service volume
may cause underuse even while reducing overuse. Although
the geographic variation data on cardiac imaging studies,
PCI, and CABG cannot be used to specifically measure the
extent of overuse, the American College of Cardiology and
American Heart Association have subsequently developed
evidence-based practice guidelines to standardize care and to
reduce variation.33
In addition, researchers have begun to develop direct
measures of overuse of healthcare services, in part flowing from the recommendations from the American Board of
Internal Medicine Foundation Choosing Wisely Campaign.
For example, Schwartz et al25 developed claims-based measures of 26 recommendations related to avoiding low-value
care and applied them to 2009 Medicare claims. Using either
a more sensitive or more specific algorithm, they estimated
that 42% or 25% of beneficiaries are affected by low-value
care, accounting for 2.7% or 0.6% total claims, respectively.25
Colla et al26 stratified Medicare patients using claims data into
low- versus high-cardiovascular-risk categories and identified that 13% (driven predominantly by ECGs) of low-risk
patients received nonindicated, low-value cardiovascular testing. Significant regional variation of overuse of cardiovascular
testing was also shown.
Although research on overuse based on claims data clearly
represents an important step toward more quantitative analysis
of overuse, translating clinical guidelines into claims analysis algorithms could result in vital clinical information being
“lost in translation.” Further research is needed to develop and
implement measures that can be applied to clinical data captured in registries and electronic medical records. Moreover,
208 Circulation July 21, 2015
such clinical measures could be compared with claims-based
estimates for the same populations to ascertain the validity (or
lack thereof) of claims-based measurement of overuse.
Causes of Overuse
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Researchers have identified a wide array of forces that contribute to the use of low-value services, all of which are likely
implicated in cardiology. Conceptually, these forces can be
categorized into clinical, financial, cultural, or legal drivers of
overuse (Table 3). Clinical drivers include a traditional professional training style that promotes the development of a broad
and exhaustive differential diagnosis, paucity of information
about the appropriate use of alternative tests and treatments,
lack of systematic comparative effectiveness research (CER)
to support evidence-based treatment protocols, and insufficient patient education about the potential harm from overuse.
Even when evidence exists, it is slow to disseminate among
physicians and may not lead to change in practice patterns
because of status quo bias and individual, team and organizational barriers to learning.34
Financial drivers are likely to be an important impetus
for overuse. Of particular concern is fee-for-service payment,
which provides a financial incentive to deliver tests and treatments regardless of patient benefit, rewarding service intensity
and volume instead of value.35 Similarly, generous insurance
coverage encourages patients to seek more healthcare services
and may reduce physician concerns about financial burden
from overtreatment. Direct financial incentives are clearly not
the only factors that drive overuse, however, as evidenced by
the geographic variation in overuse as measured by Medicare
claims despite a single benefit design and only modest geographic differences in reimbursement rates.
Commentators have pointed to a culture in medicine that
promotes action over inaction, which may be reinforced by
physician training style, malpractice concerns, and local
norms.36 A Dartmouth Atlas analysis of 23 academic training
programs around the country showed a correlation between
the supply of cardiologists and visits to cardiologists per 1000
Medicare enrollees among hospital referral regions, a 3.2-fold
difference in CABG rate, and a 2.6-fold difference in PCI
rate across the 23 top training programs.37 A similar culture
appears to be prevalent among American consumers, who
appear to be more willing than their European counterparts
to support investments in technological innovation in health
care.38 Direct-to-consumer marketing of pharmaceuticals,
devices, and other technologies almost surely contributes to
excessive use of these products, in keeping with an inflated
impression of their value. The counterargument in support
of a more conservative management strategy, that sometimes
less is better and safer, often remains ignored or suspected
of alternative motives, especially when endorsed by insurance
companies.
Despite the fact that performance data such as acute myocardial infarction and CABG outcomes have been made available to the public, there is no evidence of a consistent effect
on consumer behavior.39 Even motivated consumers of health
care may be constrained by “bounded rationality” because
individuals make decisions limited by the cost of the information (Do they have the time and access to reliable quality
information at the time of an acute myocardial infarction to
choose the best hospital?) and cognitive limitations (Do they
have the knowledge and ability to understand complex performance data presented to make the right choice?).
Finally, physicians report (and researchers have observed
in practice) that the specter of medical liability causes them to
order additional tests and treatments. Although the magnitude
of increased use that results from malpractice concerns has
been estimated as modest overall (≈2% without differentiating
low-value from high-value care), it appears to play a disproportionate role in physicians’ perceptions of cost drivers.40,41
Table 3. Overuse in Cardiovascular Medicine: Causes, Evidence, and Opportunities for Reform
Causes of Overuse
Summary of Evidence
Opportunities for Reform
Clinical drivers
Providers:
Lack of adequate evidence
Delay in knowledge dissemination
Ineffective provider behavior change
Patients:
Insufficient data for potential harm and side effects
Lack of SDM
Comparative effectiveness research
Multipronged knowledge dissemination
Performance measurement, feedback, and continuous quality
improvement
Built-in clinical decision support in electronic medical record system
Patient education and SDM
Financial drivers
Providers:
Fee-for-service reimbursement
Compensation structure to reward production
Patients:
Generous insurance coverage
Industry:
Technological and pharmaceutical advances with high profit margin
Direct-to-consumer marketing
Payment incentive for providers to reward value: bundled payment,
risk/cost sharing, pay for performance, global payment
Price transparency for both providers and patients
Value-based insurance design to promote patient choice of high-value
services
Prior authorization, case review
Cultural drivers
Providers:
Procedural and intervention focused
Patients:
Action over inaction
Better clinical evidence and education
Legal drivers
Providers:
Malpractice concerns and defensive medicine
Tort reform
CER indicates comparative effectiveness research; and SDM, shared decision making.
Huang and Rosenthal Reducing Overuse in Cardiovascular Medicine 209
Given that systematic evidence on overuse is lacking,
inferences about the relative contribution of each of these
causes of overuse are necessarily speculative. Moreover, even
at a conceptual level, it is challenging to disentangle the causes
of overuse. For example, is the culture of medicine that when
in doubt action is preferable to inaction an independent driver
of overuse or a consequence of the reimbursement model?
As large database studies of overuse that leverage advances
in data and measurement grow in number, more sophisticated
causal analyses will be possible, and these may set the stage
for identifying policy priorities.
Opportunities for Reform
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Efforts to address overuse of cardiovascular services may
take a variety of forms and address 1 or more of the underlying causes of overuse, as outlined in Table 3. We highlight a
few areas in which reforms appear to be gaining traction. In
some cases, these initiatives specifically target cardiovascular
care, but payers and policy makers have generally approached
overuse in an undifferentiated manner with the goal of cost
control.42 Conceptually, interventions to reduce overuse of
cardiovascular services can be organized in terms of whether
they operate through patient behavior, through physician
behavior, or by direct regulation of health system capacity.
Although physicians make the majority of complex healthcare decisions, patients are increasingly willing and able to
share in decision making for their care. In the case of complex choices with significant health consequences, patients
need accessible information and support to play a meaningful
role in selecting high-value care. Decision aids and a framework for SDM have been developed and used effectively in
a number of conditions, including prostate and breast cancer
treatment and treatment of low back pain. SDM is becoming a major priority of research for cardiovascular medicine
in terms of its conceptual design, its data collection, and the
measurement of its effectiveness.43 Thus far, there is modest
evidence that SDM reduces the intensity and cost of care.44
Limitations of this approach include lack of time or motivation to engage in the process on the part of physicians, the limited set of clinical decisions for which decision aids have been
developed, and the plausible set of comparatively effective,
preference-sensitive choices for which SDM might enhance
patient compliance and clinical outcome.
In addition to engaging patients individually in SDM,
patient information could be a lever for reducing overuse at
a population level. Recent efforts by Consumer Reports in
partnership with the American Board of Internal Medicine
Foundation have produced accessible information for patients
to inform them about services of questionable value, including
routine cardiac stress testing.45
Patient financial incentives, particularly in the form of
higher cost sharing, may also affect overuse. Copayments and
deductibles have been shown to reduce the use of all types of
healthcare services, but evidence shows that patients do not
have discriminative ability to ration their own care according to value; that is, they eliminate use without differentiating appropriate from inappropriate services.46 Targeted cost
sharing, known as value-based insurance design, has been
proposed as a response to the finding that blunt patient cost
sharing eliminates both necessary and unnecessary care.
However, value-based insurance design has been used largely
to promote high-value services by lowering or eliminating
copayments and to the best of our knowledge has yet to be used
as a tool for reducing overuse, particularly for cardiac care,
because doing so might be considered ethically contentious.47
Given the role of physicians in healthcare decision making, it is not surprising that the focus of policy to reduce overuse of low-value services has been in the realm of evidence
base, performance measurement, decision support, and payment incentives. Providing practicing physicians with valid
information about the comparative effectiveness of screening,
diagnosis, and treatment is essential for improving the value
of care. As noted earlier, cardiovascular medicine has been
fertile ground for such evidence development. However, adoption of new information about treatment effectiveness can be
slow. Likewise, cardiology has been at the forefront of guideline development with evidence- and consensus-based best
practices identified not only for treating specific conditions
but also for avoiding overuse. Dissemination of guidelines,
however, is no guarantee that the guidelines will be followed
and alone is a weak tool for changing behavior, particularly
when countervailing financial incentives are strong, as is
typically the case for overuse. Although efforts at refining the
AUC have resulted in decreasing the amount of unclassifiable
studies based on AUC criteria, the percentage of inappropriate studies has not been shown to improve spontaneously
over time or simply with traditional strategies of physician
education.48,49
A number of additional tactics to reduce overuse could
be implemented on the basis of the opportunities for reform
identified. First, when possible, the electronic medical record
should alert providers when circumstances of potential overuse are noted. Decision support that flags a possible overuse
situation and makes preferred, appropriate care the default
option for order entry may be effective.50 In addition, didactic
teaching, when combined with an electronic pocket card with
AUC tips, individualized e-mail performance feedback, and
smartphone application use, may help to improve appropriate
referral to cardiac imaging tests.51,52
Second, price transparency for both providers and patients
may help foster a shared sense of stewardship and awareness of at least the immediate costs of testing and treatment.
Despite compelling rationale for price transparency to control
unsustainable healthcare cost growth and rare partisan agreement on the necessity for price transparency, barriers and
challenges remain. With increasing cost sharing for both providers and patients of health care, there is increasing demand
for price transparency from both the supplier and consumer
sides of health care. Furthermore, the generational shift of
healthcare consumers and technological innovations are making price transparency and consumer choice increasingly
possible. Insurance companies such as Aetna, Health Care
Service Corp, and UnitedHealthcare are making price and outof-pocket cost information available to their members. Private
firms such as Castlight, Change Healthcare, and Cost of Care
are using social media, Web, and smartphone-based applications to provide price information to both providers and consumers of health care.53,54
210 Circulation July 21, 2015
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Finally, payment incentives for the ordering physician
may be altered to address overuse. This can be done within
the incremental changes to the current payment system by
cutting the level of fee-for-service reimbursement, eliminating coverage for services in certain conditions, or introducing
bonuses or penalties related to rates of testing or treatment.
More significant payment reform appears to be taking hold,
however, and overuse may be affected by a new paradigm
in which providers are held accountable for the total cost
of care. The predominant payment reform model is a global
risk-sharing arrangement, often associated with accountable
care organizations or similar concepts of integrated delivery
systems. To a lesser degree, bundled payment models are
being tested, largely in the context of Medicare and focused
on acute episodes that begin with an inpatient hospital admission, many of which involve patients with cardiovascular conditions. To the best of our knowledge, there is no evidence
of the effectiveness of any single payment model as a tool
for reducing overuse specifically. At a high level, however,
the evidence suggests that risk sharing reduces use and total
cost,55–57 whereas pay for performance has had a much more
mixed record of success.58 A critical question for the ongoing research on global and bundled payment initiatives (eg,
Medicare’s Accountable Care Organizations Shared Savings
Program and Bundled Payment for Care Initiative) is whether
these approaches, which effectively encourage reduction in
costs regardless of value, have a disproportionate effect on
overuse. As many have noted, any such gains would need to
be weighed against potential adverse consequences such as
avoidance of patient groups for whom meeting clinical quality
or spending targets is more challenging.
The list of potential approaches to controlling overuse
would not be complete if “command and control” mechanisms
were omitted. At a microlevel, overuse could be controlled
in part through prior authorization whereby physicians are
required to justify the appropriateness of a test or treatment
before its delivery to receive payment. Such prior authorization was more common in the 1990s during the height of the
managed care era and, although less common now, continues
for certain high-cost interventions. Although prior authorization programs such as radiology benefit management exist in
practice, evidence of an impact of radiology benefit management has been limited and anecdotal.59,60 Moreover, radiology
benefit management programs have been criticized as lacking
quality control and transparency and having only fair correlation with published AUC or other practice guidelines.61,62
At a macrolevel, policy makers have historically used
certificate of need programs to control the supply of services
with high fixed costs and risk of overuse. Certificate of need
programs have been used for cardiac catheterization facilities, among other services. Limited data demonstrate that certificate of need programs are associated with reduced early
revascularization in patients with acute myocardial infarction
without compromising quality of care,63 but their effectiveness for reducing overuse has not been demonstrated specifically. Moreover, these policies have been rolled back to a great
extent because of the politically sensitive issue of governmentimposed regionalization of care and the perceived downside of
limiting competition.
Indeed, there are insufficient data to suggest which of
these strategies specifically has been successful at reducing
overuse. Often, clinical evidence evolution coincides with
policy intervention contemporaneously, making it difficult to
tease out the specific cause-and-effect relationship. For example, despite significant growth of cardiovascular imaging test
use from 1996 to the early 2000s, the temporal trend in stress
testing showed a slow decline from 2005 to 2008. This temporal trend coincides both with the publication of AUC for
myocardial perfusion imaging and stress echocardiography
and with reimbursement cuts for imaging tests.64
Looking Ahead
Overuse in health care in general and in cardiovascular care in
particular is pervasive, and its effects are often underestimated
by clinicians. Overuse is not only costly to healthcare consumers individually and society collectively but also harmful
to patients with potentially unnecessary (and often invasive)
downstream testing and treatment. Given the evidence of
overuse described above, cardiac imaging, echocardiography
and nuclear myocardial perfusion imaging in particular, is
likely where we should invest significant time and effort to
reduce overuse, given their potential for the cascading effects
of downstream low-value care.
Two key observations relevant to the design of future initiatives to reduce overuse emerge from our review of the evidence on overuse in cardiology. First, there is no single factor
that explains the majority of overuse; thus, no single policy
intervention exists to eliminate overuse. Instead, a complement of clinical, economic, and policy strategies will help
reduce overuse and improve the value of healthcare delivery
(Table 4). Second, despite decades of efforts to develop consensus in the profession on the circumstances in which tests
and treatments are appropriate (ie, clinical benefits exceed
clinical risks) or cost-effective (ie, clinical benefits exceed
the incremental opportunity costs of the service), all of these
decision rules yield large numbers of uncertain cases. In other
words, there is very little cardiovascular care that the majority
of cardiologists would agree constitutes clear overuse. Even
when these criteria are objectively defined, the algorithms
require detailed clinical and behavioral information and medical history, which are not systematically available in electronic
billing or structured medical record data. These features of the
overuse landscape leave us with an awkward tension: Most
cardiologists would agree that overuse exists and is substantial and that the current guidelines, criteria, and recommendations describe its boundaries, but there would be much less
consensus on which individual cases belong inside or outside
those boundaries. Thus, policy mechanisms that rely on strict
coverage limitations or the use of claims-based measures of
overuse for payment and reporting are likely to be extremely
controversial. Instead, cardiologists and other physicians who
order cardiovascular services should be held accountable for
the cost of these services at a population level, with information and support for cost-conscious and value-based choices.
More specifically, a gradual transition from fee-for-service to
bundled payment, risk sharing, specialty-based subcapitation,
or global payment models is required. Although such accountability is not without potential adverse effects, including
Huang and Rosenthal Reducing Overuse in Cardiovascular Medicine 211
Table 4. Strategies and Recommendations to Reduce Overuse in Cardiovascular Medicine
Strategy
Develop better data and more effective tools to
bring about change in clinical practice
Recommendations
Make more CER data available to guide the choice of optimal diagnosis and treatment pathway.
Place a bigger emphasis on health economic analysis of emerging diagnostic and treatment innovation.
Develop specific and actionable measure of overuse.
Reduce the translational gap between guideline and practice by bringing about changes in physician behavior.
Align economic incentives to reduce overuse and Shift payment model from fee-for-service toward bundled and global payment to incentivize risk sharing and reward
promote higher value
value.
Adjust relative reimbursement to promote clinical activities that would result in better overall care.
Consider more stringent regulation of specialized services on the basis of regional need to optimize access.
Better align patient’s interest and needs with
that of high-value care
Enhance quality, cost, and health information transparency to allow patient engagement and SDM.
Leverage cost sharing, value-based insurance design to align patient financial incentive with better value.
Implement effective disease management programs to ensure behavioral modification and adherence
of treatment plans.
CER indicates comparative effectiveness research; and SDM, shared decision making.
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stinting and avoidance of high-risk patients, it has the singular
benefit of preserving a substantial role for clinical judgment at
the point of care.
Along with a shift in financial accountability, better clinical data and more effective tools are needed to change clinical
practice and to reduce overuse. Lack of robust evidence about
the most clinically effective interventions likely contributes to
overuse of health care. CER is intended to promote optimal
clinical decision making based on research results comparing
alternative strategies for the prevention, diagnosis, treatment,
and monitoring of health conditions. The Institute of Medicine
CER priority list includes 8 cardiovascular clinical issues such
as risk stratification for coronary heart disease and noninvasive stress testing, management of stable coronary disease,
and advanced heart failure therapy. A National Heart, Lung,
and Blood Institute–sponsored expert panel made detailed
recommendations for a framework of evidence and specific
studies for future research directions on cardiovascular CER
to have real-world impact.65
Beyond clinical effectiveness research, the United States
should consider greater openness to health economic analysis
for emerging diagnostic and treatment strategies. Although in
other countries information from economic studies is used to
inform health policy and coverage, economic analysis is explicitly avoided in the United States. It is unlawful for the US Food
and Drug Administration to take cost into consideration when
making safety and effectiveness assessment of a new technology. The Centers for Medicare & Medicaid Services do not
use cost-effectiveness data explicitly when making coverage
decisions.66 The Agency for Healthcare Research & Quality
does not have the authority to evaluate the cost-effectiveness
of treatments when conducting CER.67 From a population and
societal standpoint, with inexorably rising healthcare costs
in the United States, insulating health policy decisions from
health economics may no longer be a sustainable luxury. To
this end, the cardiovascular community has taken the lead to
provide incremental cost-effectiveness analysis in addition to
clinical comparative effectiveness, especially among emerging, high-cost technology such as transcatheter aortic valve
implantation and identified specific high-risk patient populations in whom the technology may not be cost effective.68
Although it is apparent that clinicians respond to clinical trial data, CER findings, or economic analysis, it must be
pointed out that a significant translational gap exists between
evidence and practice.69 To reduce overuse, it is first critical to
develop specific and actionable measures of overuse, building on clear conceptual framework, sound scientific evidence,
and consensus on the types of measures and their appropriate
use. A recent review identified only 37 specific measures with
defined patient population, clinical situation, and intervention
among 160 potential overuse measures.70 Administrative and
clinical data and, in some cases, patient input are needed to
make these specific measures fully operational, highlighting
the complexity of overuse measurement and its applicability
for audit and feedback, public reporting, and payment determination.71 Furthermore, newer, more effective methods of
physician behavior change such as direct physician engagement,72 clinical performance vignettes,73 and clinical decision
support74 will need to be used. To date, few published reports
have used AUC specifically as quality improvement tools to
reduce overuse.75 A recent randomized, controlled trial of resident and fellow education to increase appropriate use of echocardiography showed significant improvement in the inpatient
setting.76
Although the evidence of the impact of patient cost sharing on the use of appropriate versus inappropriate services
provides caution against overreliance on patient incentives
to discipline overuse,77 patients may also have a role to play
in rationalizing cardiovascular care. With the advent of the
Internet and social media, patients, as consumers of health
care, are becoming more sophisticated and engaged. At the
same time, patients have begun to have more financial exposure through high-deductible health plans and tiered networks that stratify providers on the basis of cost and quality.
Although these strategies have inherent limitations, each may
be used selectively and in conjunction with other interventions
to achieve the shared goals of reducing overuse and achieving
higher-value health care.
Moving forward, it is vital to bring the clinical, economic,
and patient perspectives into consideration when addressing the issue of overuse. Expanding the notion of overuse to
include not only the benefit/harm but also the benefit/cost tradeoff and patient preference will require a significant cultural
shift. This expanded viewpoint will also help shed light on the
measurement of overuse and reduce the tension between the
clinical and policy interventions to address overuse.
212 Circulation July 21, 2015
Conclusions
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Cardiovascular medicine has seen remarkable technological progress in the last half-century and by any measure has
delivered enormous value to individual patients and society.78
Nonetheless, cardiovascular services currently represent a
substantial proportion of the costs of an increasingly unaffordable US healthcare system. Moreover, new technologies
with high reimbursement rates are at risk of overuse in a feefor-service system, and there is growing evidence that cardiovascular services are no exception. The good news is that the
profession has a long history of proactive, scientifically rigorous approaches to improving patient care. Cardiologists need
to build on their guidelines and AUC to find clinically and professionally acceptable ways of eliminating low-value service
delivery. The opportunity to define the terms by which overuse
is addressed is now, while payment reform gains momentum.
Failure to take ownership of the problem could well leave cardiologists open to increased rationing efforts by payers and
referring physicians.
Disclosures
None.
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Key Words: cardiovascular diseases ◼ cost–benefit analysis ◼ economics,
medical ◼ health care reform ◼ health policy ◼ quality of health care
Overuse of Cardiovascular Services: Evidence, Causes, and Opportunities for Reform
Xiaoyan Huang and Meredith B. Rosenthal
Circulation. 2015;132:205-214
doi: 10.1161/CIRCULATIONAHA.114.012668
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