Overuse of Cardiovascular Services

Cardiovascular disease is the leading cause of death in the United States and constitutes 17% of overall national health expenditures,1 with noninvasive testing contributing much of the cost growth in recent years.2,3 Cardiovascular medicine has long been at the forefront of evidence-based practice, with arguably the longest-standing and most comprehensive array of efforts to measure risk factors and outcomes, to analyze the clinical effectiveness and cost-effectiveness of treatment options, and to formulate practice recommendations.4,5 Professional societies for cardiovascular medicine have established health policy statements,6 national databases on quality,7 clinical guidelines,8 and appropriate use criteria9 (AUC) for high-cost cardiovascular services (Table 1). More recently, the profession has taken steps to right-size cardiovascular services by defining the problem of overuse and underuse and working to shape clinical and policy interventions that improve quality and access and reduce unnecessary cost.10 For example, the American College of Cardiology Wisconsin and Florida chapters recently received a $15.8 million Centers for Medicare & Medicaid Innovation grant to pilot a comprehensive cardiovascular program to improve quality and to reduce cost of cardiovascular care through better data transparency, patient engagement, and shared decision making (SDM).View this table:Table 1. Summary of Initiatives to Identify and Reduce Overuse in Cardiovascular MedicineDespite efforts to improve the value of cardiovascular care, there is a concern that significant overuse of cardiovascular services persists in the United States. The published evidence of overuse is necessarily incomplete for 2 key reasons. First, for many tests and treatments, there is a lack of agreement on the basic definition of overuse. The Institute of Medicine originally defined overuse as occurring when “a health care service is provided under circumstances in which its potential for harm exceeds the possible benefit”.11 Others have since expanded the notion of …