The Cleveland Clinic is known by many as THE BEST place for heart care in America. Similar to other large, esteemed medical institutions, it has its own medical journal as well—the Cleveland Clinic Journal of Medicine. There is a great article in the July 2014 issue entitled “Is Cardiac Stress Testing Appropriate in Asymptomatic Adults at Low Risk?”.
The overall point of the article is this: Potentially too many people are receiving cardiac stress tests who do not need them. The article states, “Cardiac stress testing is often used inappropriately in people at low risk.” One group who does not need them are (1) people without symptoms (i.e. no chest pain or abnormal shortness of breath with exercise) who (2) are at low risk for cardiovascular disease (i.e. no high blood pressure, no high cholesterol, non-smoker, etc.).
Many middle age people fall into this category. Many people are ‘worried’ about their heart in middle age and want to have a cardiac stress test just to make sure their heart is ‘Ok.’ For these ‘worried well’ a cardiac stress test is of no benefit and is a waste of money. More importantly, having a cardiac stress test may even put them in HARMS WAY.
How is this so? How could a simple screening test actually cause harm?
The reason is that almost all tests are capable of having a FALSE POSITIVE RESULT. A false positive result is where a test indicates there is an abnormality when in fact there is NONE—everything is healthy and normal. The lower the risk of an abnormality in general (i.e. heart disease in a normal middle aged person), the greater the likelihood of a false positive.
So let’s say a person does have a cardiac stress test that is ‘abnormal.’ The next step is to have a cardiac catheterization—an invasive test where a cardiologist needs to ‘snake’ a catheter in the artery of the arm or the groin up into the heart and shoot dye into the arteries of the heart and then take pictures with a moving x-ray machine. A cardiac catheterization can more definitively tell if there is a blockage in an artery of the heart. The problem with the cardiac catheterization is that it carries with it a 1.7% chance of a serious adverse event such as stroke, heart attack or even death (this stat is from the article). That’s 1 out of every 59 cardiac catheterizations result in a serious adverse event.
Wasted money aside… inappropriate cardiac stress testing can lead to unnecessary cardiac catheterizations that have a low—but very real—chance of hurting you.
What does this mean for employee benefits professionals and healthcare consumers?
- Cardiac stress tests can cost anywhere from $200 – $5,500 and are not necessary for many of the people that are getting them.
- Cardiac stress tests may be a good area where increased utilization review would be beneficial.
- Leading providers like the Cleveland Clinic recognized this overutilization of cardiac stress tests and are working to spread the word regarding clinical appropriateness.