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While stress tests before joint replacement surgery started to fall out of favor at the end of 2006, they actually increased for the lowest-risk patients, one report showed.

Cardiac stress testing in the 60 days before elective total hip or knee arthroplasty followed several distinct temporal trends from 2004 to 2017, according to a large insurance claims-based dataset:

• 2004 Q1 to 2006 Q3: frequency of stress testing significantly increased 0.65% per year, reaching an estimated peak of 14%
• 2006 Q4 to 2013 Q4: frequency significantly decreased by 0.71% per year
• 2013 Q4 to 2017 Q4: frequency significantly decreased by 0.41% per year, reaching a low of approximately 7%

"The reason for this decline is likely multifactorial because it occurred with a national focus on use and costs, with a shift to the value-based health care era," said study authors led by Daniel Rubin, MD, MS, of University of Chicago. A manuscript was published online in .

The overall findings are consistent with trends reported , likely driven by the same factors, Rubin's group said.

"The guidelines have consistently de-emphasized preoperative cardiac testing prompted solely by the upcoming surgery in the absence of signs or symptoms that would warrant testing outside of the preoperative setting. Additionally, over the last 2 decades, there has been an increased national focus on potential overuse of cardiac testing," the investigators said.

However, for people going into surgery with zero cardiac risk factors on the Revised Cardiac Risk Index (RCRI, encompassing ischemic heart disease, heart failure, insulin therapy for diabetes, cerebrovascular disease, and chronic kidney disease), stress tests grew significantly in frequency from 44.7% in 2004 to 52.6% in 2017, according to the study.

These are patients "for whom preoperative stress testing was specifically discouraged by the . This finding suggests limited adherence to the guidelines and an opportunity for further reductions in preoperative stress testing," Rubin and colleagues said.

During the study period, perioperative complications for MI and cardiac arrest occurred in 0.14% of patients without any RCRI conditions and 0.58% of those with at least one such comorbidity, decreasing in both groups over time.

"Surprisingly, the complication rate of patients with zero RCRI conditions who received a stress test was twice the rate of patients with zero RCRI conditions who did not receive a stress test. This difference suggests that the RCRI may not fully account for the in our cohort," study authors added.

Among people with at least one cardiac risk factor, the incidence of MI and cardiac arrest was similar between those who had a preoperative stress test vs those who didn't (0.60% vs 0.57%, P=0.51).

"Additional investigation is needed to evaluate the optimal patient conditions that would warrant stress testing and whether our results are generalizable to other surgical procedures," the researchers concluded.

Investigators conducted their cross-sectional study of patients undergoing surgery using inpatient and outpatient health care claims from the IBM MarketScan Research Databases. Included were more than 800,000 people with private insurance (median age 62 years, 58.1% women) who underwent total hip and knee arthroplasty procedures.

Patients who received a preoperative stress test were more likely to be older (median age of 66 years vs 62 years) and male (45.8% vs 41.5%).

Rubin and colleagues acknowledged that the claims data they relied on could have missed some patient information, such as relevant comorbidities. Their dataset also wasn't nationally representative, given the underrepresentation of Medicare beneficiaries. Another limitation was that patients who had surgical plans changed by a positive preoperative stress test result were not captured.

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