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NEW ORLEANS -- Not all health systems are cutting back on cardiac stress testing, according to a population-based study reported here.

Analysis of Clinformatics Data Mart information on some 33 million commercially insured patients revealed that stress testing grew in popularity from 2005 to 2009 -- rising to 3,933 from 3,486 per 100,000 person-years -- and then falling back to 3,589 tests per 100,000 person-years by 2012.

Overall, there was a 3.0% increase in cardiac stress testing from 2005 to 2012, according to , of Hospital of the University of Pennsylvania in Philadelphia, who presented his oral abstract during the annual American Heart Association meeting. The study was published simultaneously online in .

Much of the overall increase was concentrated in people 25-34 years old. Cardiac stress testing increased 59.1% in this group during the study period, from 543 to 864 tests per 100,000 person-years. The 55-64 age group, on the other hand, saw stress testing rates fall by 12.3%.

Those figures in particular seemed to "suggest that observed trends in the use of cardiac stress testing may have been driven more by unique characteristics of populations and health systems than national efforts to reduce the overuse of testing," Kini's group wrote.

Yet , of David Geffen School of Medicine at UCLA, told MedPage Today that he was unsure of that conclusion.

"They use a huge dataset, which is fantastic, but they're largely focused on privately insured patients," Ladapo said. "We showed in prior work that patients with private insurance were more likely to receive a stress test than patients primarily insured by Medicare or Medicaid, or patients without insurance. Data in the Medicare population has very strongly shown a decline in stress test trends over the last few years."

"Public policy definitely affects test use, especially when those policies affect the finances of physicians and hospitals. There are also many competing factors but policies can definitely reduce inappropriate care," Ladapo said, citing the the Choosing Wisely campaign, reimbursement reductions, and adoption of prior authorization by insurers.

Kini's group suggested that the reduction in stress testing previously reported in other populations -- be it Medicare or Kaiser Permanente -- can be attributed to different organizational characteristics of the health systems.

"Integrated health systems, such as Kaiser Permanente, use capitated payment models without direct financial incentives to perform testing, which often leads to lower use of procedures compared with traditional fee-for-service payment models. These health systems often emphasize quality measurement and accountability, which could further contribute to declines in use of procedures."

Ladapo expressed a desire to see more clinical data from the study, including how many patients had chest pain, shortness of breath, or other important symptoms that affect cardiovascular risk. "These are all part of the picture," he reasoned.

On closer look at the data, stress echocardiography rose 12.5% during the study period, the authors reported, while other stress testing modalities jumped 65.5% from 2006 to 2012. The only modality that fell in popularity over the years was nuclear single-photon emission CT (SPECT), use of which was reduced by 14.9%.

"From a timing perspective, I think the decrease in SPECT is probably due to increased attention being paid to appropriateness and radiation exposure that was occurring during the period around 2010," suggested , of Columbia University Medical Center. "However, there is likely some substitution for other stress modalities given overall increase in stress test rate."

Commenting to MedPage Today, Ye emphasized the role of physician education regarding appropriate use criteria to "encourage more judicious stress testing."

"The key is to figure out ways to integrate smart decision support for determining appropriateness into physician workflow, with incentives to avoid rarely appropriate testing," he noted.

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