To the Editor
The Choosing Wisely (CW) campaign, which commenced in 2011, focuses on reducing medical services that are of questionable value or may be harmful.[1] In 1996 and 2002, guidelines from the American College of Cardiology and the American Heart Association implied that routine stress testing prior to low-risk surgeries should be avoided; this was codified in the 2007 guidelines because the risk of cardiac complications from these surgeries is very low.[2] Consequently, seven specialty societies for the CW campaign now recommend not performing cardiac stress testing prior to low-risk surgery.[3] Recently, Thilen documented that the rate of pre-operative consultation for cataract surgery in 2006 approached 20% among Medicare patients, but did not comment on the use of stress testing.[4] Therefore, we sought to determine the prevalence of cardiac stress testing prior to low-risk surgeries, before the CW campaign commenced, to estimate the potential impact of the recommendations on future resource use. We examined pre-operative stress testing utilization in the two largest U.S. federally-sponsored healthcare programs: the Department of Veterans Affairs (VA) and fee-for-service Medicare.
Methods
We performed a retrospective cohort study using data from VA's Corporate Data Warehouse and from a nationally representative 5% sample of Medicare fee-for-service claims. Using Current Procedural Terminology codes, we identified all asymptomatic patients age ≥65 years who underwent one or more cataract surgeries, knee arthroscopies, or shoulder arthroscopies from February-December 2009. Then, using an approach similar to Schwartz, we examined the proportion of these patients who had an exercise or pharmacologic ECG-treadmill, echocardiographic or nuclear stress test in the 28-day period prior to their first low-risk surgery.[5] To isolate routine pre-operative stress tests, we excluded stress tests in the preoperative period that also occurred 0-30 days after a hospitalization or 0-3 days after an emergency room visit. We also examined a more “sensitive” measure without such exclusions. To assess regional variation, we estimated stress test rates by hospital referral region (HRR) using 2-level empty logit models. The Ann Arbor VA Human Studies Committee and the Kaiser Permanente of the Mid-Atlantic States institutional review board approved this study.
Results
22,670 VA patients and 109,270 Medicare patients had a cataract surgery, knee arthroscopy, or shoulder arthroscopy from February-December 2009. The average age of patients was 75.5 in VA and 75.8 in Medicare (Table 1). A routine pre-operative stress test preceded one of the three low-risk surgeries in only 0.67% of VA patients and 2.14% Medicare patients (Table 2). Estimated stress test rates by HRR ranged in VA from 0.32% to 2.02% (interquartile range (IQR): 0.44% to 0.74%) and in Medicare from 1.49% to 3.14% (IQR: 1.77% to 2.11%). Applying the more sensitive measure, 0.76% of VA patients and 2.40% of Medicare patients had stress-testing prior to surgery.
Table 1. Characteristics of patients having a low-risk surgery (arthroscopy1,2 or cataract surgery3) between February 2009 and December 2009.
| Characteristic | VA (N=22,670) | Had a Stress Test (N=151) | Medicare (N=109,270) | Had a Stress Test (N=2,358) |
|---|---|---|---|---|
| Age as of 1/1/2009, mean (sd), years | 75.5 (6.7) | 73.8 (5.9) | 75.8 (6.2) | 75.3 (5.9) |
| Male, N (%) | 22,137 (97.6%) | 146 (96.7%) | 51,347 (47.0%) | 1,290 (54.7%) |
| Diagnosis of CV risk factors4 in 2009, N (%) | ||||
| Coronary artery disease | 7,887 (34.8%) | 89 (58.9%) | 63,155 (57.8%) | 1,964 (83.3%) |
| Ischemic stroke or TIA | 1,718 (7.6%) | 15 (9.9%) | 5,559 (5.1%) | 131 (5.6%) |
| Hyperlipidemia | 14,827 (65.4%) | 114 (75.5%) | 86,323 (79.0%) | 2,071 (87.8%) |
| Heart failure | 2,699 (11.9%) | 32 (21.2%) | 21,737 (19.9%) | 537 (22.8%) |
| Cardiac arrhythmias | 4,341 (19.1%) | 43 (28.5%) | 34,592 (31.7%) | 826 (35.0%) |
| Peripheral vascular disease | 3,381 (14.9%) | 26 (17.2%) | 25,346 (23.2%) | 669 (28.4%) |
| Hypertension | 17,954 (79.2%) | 127 (84.1%) | 93,585 (85.6%) | 2,136 (90.6%) |
| Diabetes | 9,666 (42.6%) | 80 (53.0%) | 42,657 (39.0%) | 1,012 (42.9%) |
| Renal failure | 3,061 (13.5%) | 26 (17.2%) | 14,853 (13.6%) | 320 (13.6%) |
| Obesity | 3,180 (14.0%) | 38 (25.2%) | 7,119 (6.5%) | 148 (6.3%) |
Knee arthroscopy (29866-29868, 29870, 29873-29877, 29879-29889)
Shoulder arthroscopy (29805-29807, 29819-29828)
Cataract surgery (66982, 66984)
Co-morbidities identified using Elixhauser coding criteria
Table 2. Proportion of patients having a stress test1 prior to a low-risk surgery2-4 between January 2009 and December 2009.
| VA | Medicare | |
|---|---|---|
| Arthroscopy (knee2 or shoulder3) | 17/1,091 (1.56%) | 703/16,079 (4.37%) |
| Cataract surgery4 | 134/21,606 (0.62%) | 1,657/93,987 (1.76%) |
| Both combined5 | 151/22,697 (0.67%) | 2,360/110,066 (2.14%) |
Stress test (75559, 75560, 75563, 75564, 78451-78454 78460, 78461, 78464, 78465, 78472, 78473, 78481, 78483, 78491, 78492, 93015-93018, 93350-93352, C8928, C8930)
Knee arthroscopy (29866-29868, 29870, 29873-29877, 29879-29889)
Shoulder arthroscopy (29805-29807, 29819-29828)
Cataract surgery (66982, 66984)
N is larger than in table 1 because some patients had both surgeries
Discussion
We found that the use of routine pre-operative stress testing prior to low-risk surgery in both VA and Medicare was very low and varied little across regions, even before the CW campaign started. Although rates in Medicare were three times as high as those in VA, these low absolute numbers suggest interventions to further decrease use would minimally improve quality (while diverting attention away from higher-yield interventions that would more strongly affect care). It appears that the vast majority of physicians had already incorporated into their practices guidelines about appropriate pre-operative stress testing before the CW recommendations. While this is good news for patients, it is not helpful for a campaign that aims to improve appropriateness.[6] Specialty societies should focus future CW recommendations on services that have high baseline rates of inappropriate care in order to call attention to areas where interventions can best improve quality.
Acknowledgments
Funding/Support: Partial funding for this work was provided by the Veterans Health Administration's Office of Informatics and Analytics (OIA). Additional support was provided by the Veterans Affairs Diabetes Quality Enhancement Research Initiative (grant DIB 98-001). This work was also supported by an Agency for Healthcare Research and Quality Career Development award (1K08HS018781-01) for Dr. Chen.
Footnotes
Additional Contributions: Rob Holleman, MPH, VA Center for Clinical Management Research, and Haihong Hu, MPH, Kaiser Permanente Mid-Atlantic States, provided assistance with data management and analysis. Contributors did not receive financial compensation.
Disclaimer: The views expressed herein are those of the authors and do not necessarily represent the U.S. Department of Veterans Affairs, the University of Michigan, or Kaiser Permanente.
References
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