Overuse of preoperative cardiac stress testing in medicare patients undergoing elective noncardiac surgery
Kristin M Sheffield1, Patricia S McAdams, Jaime Benarroch-Gampel
1Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555, USA. kmsheffi@utmb.edu
Insights
Unnecessary cardiac stress testing before surgery is common in Medicare patients without indications, increasing over time. This study found 3.75% of eligible patients received testing, highlighting a need for guideline adherence.
Area of Science:
- Cardiology
- Health Services Research
- Medical Economics
Background:
- Current guidelines recommend against cardiac stress testing for patients without cardiac indications before elective noncardiac surgery.
- Adherence to these guidelines is crucial for optimizing healthcare resource allocation and patient care.
Purpose of the Study:
- To investigate the frequency and predictors of cardiac stress testing in Medicare patients undergoing elective noncardiac surgery who have no clear indications for such evaluation.
- To assess trends in the utilization of preoperative cardiac stress testing over time.
Main Methods:
- Analysis of a 5% sample of Medicare inpatient claims data from 1996-2008.
- Inclusion of patients aged 66 years or older undergoing specific elective procedures.
- Identification of a subset of patients with no diagnoses indicative of cardiac disease (N=74,785) for focused analysis.
Main Results:
- 3.75% of patients without cardiac indications underwent preoperative stress testing.
- The rate of testing increased significantly from 1.72% in 1996 to 6.44% in 2007.
- Predictors of unnecessary testing included female sex, comorbidities, high-risk procedures, larger hospital size, and higher regional Medicare expenditures.
Conclusions:
- A significant proportion of Medicare patients without indications undergo preoperative cardiac stress testing, with an increasing trend.
- Over 56,000 unnecessary tests are estimated annually in the Medicare population.
- Improved adherence to established guidelines is needed to reduce unnecessary testing and associated costs.
Objective:
To determine the frequency and predictors of cardiac stress testing before elective noncardiac surgery in Medicare patients with no indications for cardiovascular evaluation.
Background:
The American College of Cardiology/American Heart Association guidelines indicate that patients without class I (American Heart Association high risk) or class II cardiac conditions (clinical risk factors) should not undergo cardiac stress testing before elective noncardiac, nonvascular surgery.
Methods:
We used 5% Medicare inpatient claims data (1996-2008) to identify patients aged ≥ 66 years who underwent elective general surgical, urological, or orthopedic procedures (N = 211,202). We examined the use of preoperative stress testing in the subset of patients with no diagnoses consistent with cardiac disease (N = 74,785). Bivariate and multivariate analyses were used to identify predictors of preoperative cardiac stress testing.
Results:
Of the patients with no cardiac indications for preoperative stress testing, 3.75% (N = 2803) received stress testing in the 2 months before surgery. The rate of preoperative stress testing increased from 1.72% in 1996 to 6.44% in 2007 (P < 0.0001). A multivariate analysis adjusting for patient and hospital characteristics showed a significant increase in preoperative stress testing over time. Female sex [odds ratio (OR) 1.11; 95% CI: 1.02-1.21], presence of other comorbidities [OR 1.22; 95% confidence interval (CI): 1.09-1.35], high-risk procedure (OR 2.42; 95% CI: 2.04-2.89), and larger hospital size (OR 1.17; 95% CI: 1.03-1.32) were positive predictors of stress testing. Patients living in regions with greater Medicare expenditures (OR 1.24; 95% CI: 1.05-1.45) were also more likely to receive stress tests.
Conclusions:
In a 5% sample of Medicare claims data, 2803 patients underwent preoperative stress testing without any indications. When these results were applied to the entire Medicare population, we estimated that there are over 56,000 patients who underwent unnecessary preoperative stress testing. The rate of testing in patients without cardiac indications has increased significantly over time.
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