A new study released Oct. 11 in the Journal of the American Medical Association explores the relationship between annual rates of diagnostic cardiovascular tests and changes in rates of high- and low-value testing, suggesting payment changes intended to reduce spending on overall testing may not have negatively affected testing recommended by guidelines.

Vinay Kini, MD, MSHP, et al., looked at a 5 percent national sample of Medicare beneficiaries aged 65 to 95 years from Jan. 1, 1999, through Dec. 31, 2016. Results indicated annual rates of overall testing appeared to increase from 2000 to 2008, then declined until 2016. Additionally, rates of low-value tests, including preoperative stress testing and routine stress testing after coronary revascularization, appeared to have increased, then decreased. Rates of high-value tests, such as left ventricular systolic function testing among patients hospitalized with acute myocardial infarction (AMI) and heart failure (HF), appeared to increase throughout the study period.

In general, the authors highlight that "during a period of Medicare reimbursement changes intended to reduce spending on overall testing, rates of low-value testing declined considerably while guideline-concordant testing among patients with AMI and HF was not adversely affected." While causal connections to the study could not be established, Kini and colleagues note multiple factors that could be potentially associated with these findings, including the ACC's development of Appropriate Use Criteria (AUC) starting in 2005, as well as consumer-facing efforts like Choosing Wisely, of which the ACC also is a part. "Other changes during the study period such as implementation of public reporting of hospital outcomes, vertical integration of cardiology practices into health systems, value-based physician incentives, or other clinical practice changes not addressed in guideline documents could also have contributed to the observed changes in testing rates," they write.

"The ACC developed AUC in response to concerns about rising rates of cardiovascular testing and substantial geographic variation, with the goal of providing true and trusted guidance to the practitioner," said Robert Hendel, MD, FACC, who participated the creation of AUC back in 2004 and has been highly involved in this initiative for more than 10 years. "The article by Kini and colleagues demonstrates similar findings to other studies and adds to the growing body of evidence suggesting that appropriate use can be improved via education and feedback, resulting in not only optimization of care but also in savings to the health care system through the avoidance of unnecessary testing. While the cause for improved utilization of cardiovascular testing may not be solely related to AUC, the criteria certainly have contributed to reduction of low-value cardiovascular testing. We believe that clinicians have received the message and AUC will continue to have an impact on practice patterns, to the betterment of patient outcomes."

Note: The "Educational and Operations Testing Period" of the new Appropriate Use Criteria (AUC) reporting program, established under the Protecting Access to Medicare Act of 2014, begins on Jan. 1, 2020. Currently, full program implementation is expected Jan. 1, 2021. Learn more about the program and how to prepare at ACC.org/AUC.

Keywords: ACC Advocacy, American Medical Association, Cardiology, Medicare, Exercise Test, Heart Failure, Myocardial Infarction

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