Cardiac Stress Test Trends Among US Patients <65 Years

Study Questions:

What are the rates of cardiac stress testing among a large and diverse cohort of commercially insured patients in the United States?

Methods:

A serial cross-sectional study with time trends was conducted using administrative claims from all members aged 25-64 years belonging to a large, national managed care company from January 2005 through December 2012. Linear trends in rates were determined using negative binomial regression models with procedure count as the dependent variable, calendar quarter as the key independent variable, and the size of the population as a logged offset term. Age- and sex-adjusted rates of cardiac stress tests per calendar quarter were reported as number of tests per 100,000 person-years.

Results:

A total of 2,085,591 cardiac stress tests were performed among 32,921,838 persons (mean age 43.2 ± 10.9 years; 16,625,528 [50.5%] women and 16,296,310 [49.5%] men; 7,604,945 [23.1%] nonwhite). There was a 3.0% increase in rates of cardiac stress testing from 2005 (3,486 tests; 95% confidence interval [CI], 3,458-3,514) to 2012 (3,589 tests; 95% CI, 3,559-3,619; p = 0.01 for linear trend). Use of nuclear single-photon emission computed tomography decreased by 14.9% from 2005 (1,907 tests; 95% CI, 1,888-1,926) to 2012 (1,623 tests; 95% CI, 1,603-1,643; p = 0.03). Use of stress echocardiography increased by 27.8% from 2005 (709 tests; 95% CI, 697-721) to 2012 (906 tests; 95% CI, 894-920; p < 0.001). Use of exercise electrocardiography (ECG) increased by 12.5% from 2005 (861 tests; 95% CI, 847-873) to 2012 (969 tests; 95% CI, 953-985; p < 0.001). Use of other stress testing modalities increased 65.5% from 2006 (55 tests; 95% CI, 51-59) to 2012 (91 tests; 95% CI, 87-95; p < 0.001). For individuals aged 25-34 years, rates of cardiac stress testing increased 59.1% from 2005 (543 tests; 95% CI, 532-554) to 2012 (864 tests; 95% CI, 852-876; p < 0.001). For individuals aged 55-64 years, rates of cardiac stress testing decreased by 12.3% from 2005 (7,894 tests; 95% CI, 7,820-7,968) to 2012 (6,923 tests; 95% CI, 6,853-6,993; p < 0.001).

Conclusions:

A small increase in the use of stress tests was observed between 2005 and 2012 among a nationally representative cohort of commercially insured patients.

Perspective:

After a period of rapid growth, recent declines in the rates of cardiac stress testing have been observed among Medicare beneficiaries. However, data from this study, using administrative claims for members aged 25-64 years belonging to a large, national managed care company, found trends toward increased use of stress testing between 2005 and 2012. Decreased rates of nuclear stress testing were more than offset by increased rates of stress echo and stress ECG, and decreased rates among patients 55-64 years were more than offset by increased rates among patients 25-34 years of age. These data suggest that observed trends suggesting a decreased use of cardiac stress testing among the Medicare population may have been driven by unique characteristics of populations and health systems, and might not reflect success of national efforts to reduce the rates of overall testing and of overtesting.

Clinical Topics: Noninvasive Imaging, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: AHA Annual Scientific Sessions, Angina Pectoris, Diagnostic Imaging, Echocardiography, Stress, Electrocardiography, Exercise Test, Managed Care Programs, Tomography, Emission-Computed, Single-Photon, AHA16


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