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Use of non-indicated cardiac testing in low-risk patients: Choosing Wisely
  1. Carrie H Colla1,2,
  2. Thomas D Sequist3,4,5,
  3. Meredith B Rosenthal6,
  4. William L Schpero1,
  5. Daniel J Gottlieb1,
  6. Nancy E Morden1,2,7
  1. 1The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  2. 2Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  3. 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
  4. 4Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5Partners HealthCare, Boston, Massachusetts, USA
  6. 6Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
  7. 7Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  1. Correspondence to Dr Carrie H Colla, The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, 35 Centerra Parkway, Lebanon, NH 03766, USA; carrie.h.colla{at}

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In 2011, the American Board of Internal Medicine Foundation created the Choosing Wisely initiative, which encourages physicians to be responsible stewards of finite healthcare resources.1 Through this programme, specialty societies have created lists of “Five Things Physicians and Patients Should Question”. Cardiac testing in low-risk patients appears on the Choosing Wisely lists of six specialty societies (see online supplementary table S1). A challenge in studying potential waste or creating incentives for improving healthcare efficiency is the scarcity of accepted definitions of low-value or potentially harmful care. To date, Choosing Wisely recommendations have not been translated into claims-based algorithms for measurement purposes and thus neither the prevalence of these services nor the associated spending has been estimated at a population level.

Using Medicare administrative data from 2006 to 2011, we estimated the proportion of low-risk Medicare beneficiaries receiving non-invasive cardiac screening tests without a clear, pertinent symptomatic indication, as well as the regional variation in and spending associated with these tests. For comparison and as a validation of our patient risk assignment, we measured cardiac testing in beneficiaries with or at high risk for cardiac disease.


Using the Medicare 40% denominator file, we identified all fee-for-service Medicare beneficiaries enrolled in Medicare Parts A, B and D (inpatient, outpatient and prescription coverage), 2006–2011, and created six annual enrolment cohorts (see online supplementary table S1 for an expanded version of methods). Each beneficiary was assigned a cardiovascular disease risk status (low or high) based on records in Medicare Carrier, Outpatient, MedPAR, Hospice and Prescription Drug Event files using a combination of International Classification of Disease codes and drug ingredient codes. For each annual enrolment cohort, beneficiaries with no evidence of significant cardiovascular disease or cardiovascular risk were deemed low-risk, and the remaining beneficiaries were deemed high-risk for cardiovascular disease or cardiovascular events. …

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  • Contributors CHC and NEM had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: CHC, TDS, MBR, WLS, DJG, NEM. Acquisition of data: CHC. Analysis and interpretation of data: CHC, WLS, DJG. Drafting of the manuscript: CHC, TDS, MBR, WLS, DJG, NEM. Critical revision of the manuscript for important intellectual content: CHC, TDS, MBR, WLS, DJG, NEM. Statistical analysis: WLS, DJG. Obtained funding: CHC, TDS. Study supervision: CHC.

  • Funding This study was supported by grants from the National Institute on Aging (P01 AG019783 and K23 AG035030), the Robert Wood Johnson Foundation's Changes in Health Care Financing and Organization (HCFO) Initiative (#70729) and The Commonwealth Fund (#20130339).

  • Competing interests None.

  • Ethics approval This study was approved by the institutional review board at Dartmouth College, Hanover, NH, USA.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Study data are available from the corresponding author on request.

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