As cardiovascular disease becomes a greater risk for both older and younger Americans, there may be new grounds for steering members away from traditional diagnostics.
Many of the cardiac stress tests with nuclear imaging are not clinically appropriate, exposing patients to radiation and driving some $500 million in unnecessary spending annually, according to a new study in the Annals of Internal Medicine.
In the 1990s and 2000s, the use of cardiac stress tests soared, found New York University medicine professor Joseph Ladapo, MD, and colleagues.
They studied adults with no history of coronary artery disease who were referred for cardiac stress tests between 1993 and 2010, and found that the test orders increased from 28 per 10,000 visits to 45 per 10,000 visits over the 17-year period.
The growth in simple cardiac stress tests, where patients hooked up to an ECG walk a treadmill but do not receive invasive imaging, can largely be explained by the aging population more prone to weight and obesity problems.
The 30 percent growth of cardiac stress tests with nuclear-based imaging agents cannot be explained by patient demographics, however.
At least 34 percent of those imaging-stress tests "were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer," Ladapo and colleagues write.
Cardiovascular disease is a huge health problem in the U.S. and bound to become even more so as a new generation ages with a high prevalence of diabetes and obesity -- to the extent that insurers are likely to see cardiovascular events like heart attacks in younger members, not just seniors.
Thus the prevention and risk mitigation strategy of lifestyle intervention has become a key goal. The importance of diagnosis and ruling out advanced heart disease remains, but new molecular-based tests are increasingly offering non-invasive options for patients and payers.
Aetna and others are now offering members a gene expression blood test that helps diagnose, or rule out, obstructive coronary artery disease, a condition often investigated with stress testing, electrocardiograms, CT scans, dye-based angiography or catheterizations.
Under Aetna's policy, a coronary artery disease gene expression test sold by the company CardioDX will be covered as medically necessary for non-diabetic adult members experiencing chest pain or similar symptoms without a history of the disease. Measuring the expression levels of 23 genes linked to the development and response of atherosclerosis, the test can rule out obstructive CAD and help avoid further tests.