Stress Tests Not Performed Before Most Elective Angioplasties

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Most elective angioplasties are performed without first conducting a noninvasive stress test to determine whether the procedure is necessary, according to a study published Wednesday in the Journal of the American Medical Association, the Milwaukee Journal Sentinel reports. For the study, researchers analyzed 23,887 Medicare claims and 1,630 private insurance claims. Researchers found that 45% of Medicare beneficiaries received a stress test in the 90 days prior to their elective angioplasty, and 34% of privately insured patients received the test within one year of their procedure (Fauber, Milwaukee Journal Sentinel, 10/15).

The study also found that women, patients treated by younger physicians and patients treated by physicians who perform a large number of heart surgeries were less likely to receive a stress test (Thomas, Chicago Sun-Times, 10/15). Others who were less likely to receive a stress test were people ages 85 and older and patients with another cardiac condition, such as congestive heart failure or chronic obstructive pulmonary disease. The study found that black patients and those with a history of chest pain were more likely to have the test (Ostrow/Nussbaum, Bloomberg News, 10/14). In addition, the study found variations throughout the country with physicians in the Midwest and Northeast most likely to order stress tests (Chicago Sun-Times, 10/15).

According to the Journal Sentinel, the study "is the latest indication that elective angioplasty, which has increased by 300% over the last decade, has been overused" and sometimes is performed on patients "for whom the risk outweighs the benefit." The study found that Medicare pays as much as $15,000 for each angioplasty, and the procedure accounts for at least 10% of the increase in Medicare spending since the mid-1990s (Milwaukee Journal Sentinel, 10/15).

According to an accompanying editorial, to avoid unnecessary angioplasties, guidelines should be clearer on when to conduct a stress test and Medicare payments should reflect how closely physicians follow those recommendations (Chicago Sun-Times, 10/15).

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Study author Grace Lin of the University of California-San Francisco said, "It's important to document that patients are receiving [angioplasty] for appropriate indications to ensure the optimal use of Medicare resources," adding, "What really matters is whether or not [a blocked artery] is affecting blood flow to the heart. That is why the stress test is important" (Steenhuysen, Reuters, 10/14).

Study co-author Rita Redberg, a professor of medicine at UCSF, said that there needs to be a change to the payment system so that it rewards physicians who follow guidelines and perform stress tests to see if an angioplasty is needed (Milwaukee Journal Sentinel, 10/15). "Right now we have a system that pays the same for inappropriate and appropriate care," Redberg said, adding, "There should be a restructuring of incentives" (Bloomberg News, 10/14).

Bonnie Weiner, the immediate past president of the Society for Cardiovascular Angiography and Interventions, said, "The guidelines are important, but they are meant to guide physicians based on the data available at the time of their development, not serve as a substitute for clinical judgment." The society said that the study results merit concern but noted that stress tests are not always appropriate, particularly for patients who are too ill or immobile to take them (Reuters, 10/14). The society also noted that the study looked back only 90 days to see if a stress test had been done and failed to acknowledge that the majority of patients with stable heart conditions undergo angioplasty because their medication ceases to work (Milwaukee Journal Sentinel, 10/15).

Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, and sign up for email delivery at kaisernetwork.org/email . The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2007 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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