Abstract
Owing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date. To determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits. This retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019. Eligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits). Age- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing. Mean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P < .001) and then declined to 316 in 2016 (P < .001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P < .001) and heart failure (72.6% to 80.1%; P < .001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P < .001) but then declined to 2.5% in 2016 (P < .001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P = .03) but then declined to 30.8% in 2014 (P < .001). Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.
Highlights
In the 1990s and early 2000s, the use of diagnostic cardiovascular testing such as stress tests and echocardiography among Medicare fee-for-service beneficiaries increased substantially.[1,2] Coupled with significant geographic variation in the use and expense of these tests, potential overuse of testing was a concern.[3,4,5,6,7] Beginning in 2004, the Centers for Medicare & Medicaid Services responded by implementing a series of reductions in the physician fees for inpatient and outpatient testing and the facility fees for office-based testing.[8]
Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines
Meaning Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines
Summary
In the 1990s and early 2000s, the use of diagnostic cardiovascular testing such as stress tests and echocardiography among Medicare fee-for-service beneficiaries increased substantially.[1,2] Coupled with significant geographic variation in the use and expense of these tests, potential overuse of testing was a concern.[3,4,5,6,7] Beginning in 2004, the Centers for Medicare & Medicaid Services responded by implementing a series of reductions in the physician fees for inpatient and outpatient testing and the facility fees for office-based testing.[8]. In the face of these reimbursement changes, the overall rate of testing has modestly declined.[11,12,13] to date whether these declines reflect use of high-value testing that is recommended by guidelines or low-value testing that is expected to provide minimal benefits is unknown. Prior studies suggest that payment changes intended to reduce spending on overall testing do not differentially reduce the use of high- and low-value medical procedures.[14,15] If reductions in high- and low-value testing are observed, payment changes may have had the unintended consequence of reducing guideline-recommended testing. We examined use of (1) overall diagnostic cardiovascular testing, (2) high-value testing (assessment of left ventricular function among eligible patients hospitalized with acute myocardial infarction [AMI] or heart failure [HF]),[16,17,18] and (3) low-value testing (stress testing before low-risk surgery and routine stress testing within 2 years of coronary revascularization with percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG] surgery) among Medicare fee-for-service beneficiaries from 2000 through 2016.19-21
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
