In a scientific statement released for publication, the American Heart Association Council on Quality of Care and Outcomes Research examines the issue of low-value cardiovascular care, including a discussion of the scope and impact of this problem and a review of the existing literature focusing on interventions designed to address it.^[1]Kini V, Breathett K, Groeneveld PW, et al. Strategies to reduce low-value cardiovascular care: scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. … Continue reading Based on these findings, the authors provide a framework for reducing its prevalence.

Low-value care refers to health care services which have been shown to provide no net benefit when factoring in the cost of a particular test or intervention. Calculation of net benefit typically considers the potential of the service to provide meaningful health improvements, the potential to create harm, and existing alternatives to the service in question. Layering in cost, to both patients and to society, underscores the need to find effective ways to reduce such care. The authors note that U.S. health care spending is on an unsustainable upward trajectory and cite data suggesting that 30% of that spending may be considered unnecessary or wasteful.

Cardiovascular care is particularly prone to low-value services. The high prevalence of disease, its tendency to present acutely and sometimes fatally, and rapid advances in testing and therapeutics create an environment where such care has become common.  Among other factors, the authors point to misaligned financial incentives, patient expectations, and local practice culture as contributors.

High-quality evidence, such as that generated from the ISCHEMIA trial, has identified a number of scenarios in which certain cardiac tests and interventions are considered low value. Examples include routine annual stress testing following coronary revascularization, and percutaneous coronary intervention (PCI) in patients with stable coronary disease. According to the authors, if current guidelines for PCI were to reflect the results of the ISCHEMIA trial, it is estimated that nearly 25% of elective PCIs commonly performed would be categorized as rarely appropriate. This amounts to ~200,000 procedures annually and a potential savings of $6 billion.

Interventions targeting the problem have had limited success. Among those holding promise are educational programs targeting physicians, such as Appropriate Use Criteria developed by specialty societies and the Choosing Wisely campaign published by the American Board of Internal Medicine. One study evaluating the effectiveness of these tools showed a reduction in low-value echocardiography and stress testing, but only when education was coupled with reinforcement in the form of audits, feedback, or decision support tools, thus highlighting the importance of a multifaceted approach.

Payer-level strategies such as prior authorization are associated with modest reductions in low-value services. Others, including tiered formularies and pay-for-performance programs which incentivize high-value services have shown promise, but the existing literature has not looked specifically at the rate of low-value services as an end point. Also promising were alternative payment models such as accountable care organizations (ACOs), which seek to align financial incentives with health care value.

The authors provide a framework for addressing the complex issues driving the problem and emphasize that a comprehensive solution must involve interventions at multiple levels. They caution against applying interventions that may disproportionately impact certain populations and note that some of the programs currently in place have been shown to contribute to the inequities inherent in our system. They recommend focusing on services with high baseline use and significant spend, such as the PCI example mentioned above. Finally, they cite the need for high-quality evidence focusing on existing services whose value has been questioned.

The American Heart Association is a national voluntary health agency to help reduce disability and death from cardiovascular diseases and stroke. Additional information can be found in the full text of the article. Of particular interest is Table 2 which provides a summary description of the interventions, along with the advantages and disadvantages of each. In addition, Figure 3 offers a visual representation of the framework to reduce low-value care.

Carelon recognizes the need for a comprehensive approach to reducing waste in the health care system and applaud the efforts of organizations such as the AHA to bring attention to this issue. Our cardiology programs rely on high-quality evidence and guidelines from the relevant specialty societies when determining the appropriateness of tests and services.

Kini V, Breathett K, Groeneveld PW, et al. Strategies to reduce low-value cardiovascular care: scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2022;15(3):e000105.