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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Healthy Heart Healthy Heart

Tests You May Not Need

June 27, 2013

By Thomas H. Lee M.D.

Harvard Medical School

Last reviewed by Faculty of Harvard Medical School on June 27, 2013

One of the more painful trends in health care is that an increasing percentage of costs are being shifted to the patient. You probably are seeing this in several ways. You may have to pay a higher copayment — the once-nominal fee of $5 when you went to the doctor or emergency room may have jumped to $20 or $50. Or you may have to pay 10% or 20% of whatever your health care costs. Or you may have a "deductible" — that is, the first $1,500 or even $5,000 of your health care costs are your responsibility; then and only then does insurance kick in to help.

This change isn't really bad. It's a reflection of the fact that there has been incredible progress in health care, and these advances are not cheap. However, to keep costs from soaring out of sight, we all have to do our part to minimize tests and treatments that aren't really necessary. And having financial incentives to reduce waste is a time-honored tactic that is uncomfortable, but it works.

So, now you are interested in controlling your own health care costs, but you don't want to compromise the quality of your care. Where do you look for savings? Here is a list of some common tests given for reasons that that experts agree are rarely warranted. The American College of Cardiology and the American Heart Association (ACC/AHA) have an excellent series of guidelines that classify the use of tests according to the strength of evidence supporting them. For the examples below, the expert panels said the evidence just wasn't there.

  • Routine EKGs — The ACC/AHA guidelines support use of baseline EKGs, and EKGs in patients who have had changes in their symptoms or other clinical information. But they do not support EKGs at every visit for patients with heart disease who are stable and are seen at frequent intervals (for example, every four months) and who have no new or unexplained findings.


  • Exercise tests — The guidelines do not support use of exercise tests to screen healthy people who have no symptoms that could indicate heart disease. The false-positive rate of exercise tests — results that indicate heart disease when none exists — causes more harm than good in low-risk people.


  • Echocardiography — The guidelines also do not support use of echocardiography in healthy people who have no symptoms of heart disease, or for people with mild heart murmurs.


  • Nuclear cardiology tests — These tests, which cost $1,000 or more and use up half a day of your time, are not recommended for people who are able to exercise on a treadmill and have an electrocardiogram that is free of major abnormalities. These tests are being used by some doctors as the first test for women and among the elderly, but the guidelines do not support this practice.


  • Routine annual follow-up stress tests — For people who have had angioplasty or coronary artery bypass graft surgery (CABG), and who are not having symptoms suggesting a return of their angina, the guidelines do not support routine testing. This recommendation goes against the common practice of performing routine stress tests on people once a year after angioplasty or CABG. The reason is that the results are not going to affect your care — you are not going to have another CABG when you are feeling fine.

What to do if your doctor recommends one of these tests for one of these questionable reasons? It's hard to question your doctor's recommendations, but you do have some money at stake. Rather than wonder, just ask your doctor. He or she may have a very good reason why these recommendations do not apply to you. But many doctors order these tests because they think patients want and expect them. If that is the case, feel free to tell your doctor that you would just as soon have a nice dinner out with your family.

Thomas H. Lee, M.D. is the chief executive officer for Partners Community HealthCare Inc. He is a professor of medicine at Harvard Medical School. He is an internist and cardiologist at Brigham and Women's Hospital. Dr. Lee is the chairman of the Cardiovascular Measurement Assessment Panel of the National Committee for Quality Assurance.

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