Introduction

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.