The following are key points to remember from this American Heart Association scientific statement about strategies to reduce low-value cardiovascular care:

1. Low-value care occurs for a variety of reasons, including defensive medical practices, misalignment of financial incentives, and clinical cultures, which encourage increased consumption of care. Low-value care can be considered health care services that provide no net benefit. Common clinical scenarios of low-value care can be found in the Appropriate Use Criteria or the American Board of Internal Medicine’s Choosing Wisely initiative.
2. The National Academy of Medicine reports an estimated 30% of health care spending could be considered unnecessary or wasteful. Costs savings related to reducing or eliminating low-value care is estimated to save the US healthcare system $13-$28 billion annually.
3. A meta-analysis of noninvasive testing suggests that up to 20% of echocardiograms and up to 50% of stress testing in the United States is rarely or not appropriate. Up to 70% of patients referred for invasive coronary angiography have nonobstructive disease, suggesting that these procedures are overused. An estimated 10-15% of percutaneous coronary interventions (PCIs) performed in the United States can rarely be considered appropriate. Approximately 20-25% of implantable cardioverter-defibrillators are also considered rarely appropriate.
4. Spending on low-value care potentially diverts resources from higher-value care. Annual costs of low-value cardiovascular services include an estimated $212 million to $2.1 billion for stress testing in the setting of stable coronary artery disease (CAD). Low-value care also includes an estimated $212 million to $2.8 billion associated with PCI among patients with stable CAD. Preoperative noninvasive testing, when not needed, is estimated to cost $102-$238 million annually.
5. Reducing low-value care requires more than one solution and the inclusion of multiple stakeholders, including diverse groups of patients and communities. Clinician education regarding appropriate use criteria can reduce low-value imaging but has been found to be difficult to sustain in the long-term. Clinical decision support interventions have been mixed in results, with some interventions reducing low-value care (e.g., inappropriate stress testing), while others have not found such reductions. Behavioral science approaches may also improve the use of evidence-based care while reducing low-value care; however, further research in cardiovascular care is needed.
6. Payer and health system interventions may improve rates of appropriate care. The Centers for Medicare & Medicaid Services is pursuing a Coverage With Evidence Development approach to include data from registry or clinical trials as evidence to determine coverage. Stakeholders also use prior authorization to reduce low-value care. Pay-for-performance programs may also reduce low-value care; however, further analysis and data are needed.
7. Accountable care organizations and bundled payments for episode-based care are expected to provide incentives for prevention and population health management. Data from different regions of the United States, including data on provider participation, are required to determine the impact on reducing low-value care.
8. Efforts to reduce low-value care should be combined with efforts to improve equity in cardiovascular care. Understanding efficiency of care across populations, geographic variation, and community resources is required to improve health equity. Incorporations of population health methods and frameworks such as the social-ecological model of health promotion are important to consider when designing strategies to reduce low-value cardiovascular care.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Coronary Angiography, Coronary Artery Disease, Defibrillators, Implantable, Diagnostic Imaging, Echocardiography, Exercise Test, Health Equity, Health Expenditures, Myocardial Ischemia, Percutaneous Coronary Intervention, Population Health, Primary Prevention, Quality Assurance, Health Care, Quality Improvement

< Back to Listings