Reducing unnecessary tests focus of two new articles

Between 2000 and 2007, the use of imaging studies for Medicare patients grew faster than any other physician service, and between 20% and 50% of all high-tech imaging studies provide no useful information, according to an articlepublished online first August 28 by the Annals of Internal Medicine.

The article, “The overuse of diagnostic imaging and the Choosing Wisely initiative,” cites studies with those data as part of commentary on the Choosing Wiselyinitiative announced earlier this year by the American Board of Internal Medicine (ABIM).

The initiative is designed to encourage doctors and patients to use only evidence-based, truly necessary diagnostic tests. As part of Choosing Wisely, the ABIM asked nine medical organizations, including the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP), to name five tests in their specialty that they believed to be overused.

Imaging tests named by the ACP and/or the AAFP:

• imaging for suspected pulmonary emboli in patients with low pretest probability (ACP),

• routine preoperative chest radiography in patients without cardiopulmonary symptoms (ACP),

• imaging in patients with low back pain in the absence of red flags (AAFP, ACP),

• dual energy x-ray absorptiometry for suspected osteoporosis in women aged fewer than 65 years and men aged fewer than 70 years in the absence of risk factors (AAFP), and

• brain computed tomography (CT) or magnetic resonance imaging after simple syncope without neurologic abnormalities.

The complete list of the tests named by the medical organizations is available at the Choosing Wisely Web site.

The authors of the Annals article, Vijay M. Rao, MD, and David C. Levin, MD, speculate that overuse of diagnostic imaging stems from fear of malpractice liability among many doctors-especially doctors practicing emergency medicine-the increasing presence of advanced imaging equipment in the offices of nonradiologist physicians, and growing patient demand for advanced imaging tests.

“Once patients start asking for a test, it’s very difficult for physicians to say no, even if the test isn’t medically indicated, because the physician worries about being sued for malpractice,” Rao tells Medical Economics. X-rays and head and abdominal CT scans are the diagnostic tests most frequently ordered by primary care physicians, she says.

Overuse of tests, the authors note, not only helps to inflate the nation’s overall healthcare spending but also inconveniences patients and may expose them to excessive quantities of radiation. The solution, says Rao, lies in a combination of tort reform, creating evidence-based guidelines and protocols to indicate when a certain kind of test is warranted, and leveraging the guidelines and protocols through technology.

An example of the latter, she says, is an order entry system that would prompt the ordering doctor to enter the patient’s symptoms. Based on the latest guidelines, the system would tell the physician whether the test being ordered is appropriate. Prototypes of such systems are being tested at Massachusetts General Hospital and Brigham and Women’s Hospital in Boston, Massachusetts. “I believe this is what the future holds,” she says.

The pressure from patients for more tests is fueled in part by the growing availability of ethically questionable direct-to-consumer screening tests, according to another commentary posted August 28 online by Annals. In “The ethics of commercial screening,” authors Erik A. Wallace, MD, John H. Schumann, MD, and Steven E. Weinberger, MD, note that a variety of screening tests now are offered in community locations such as pharmacies, churches, and health clubs.

Often the tests are made available through the sponsorship of a hospital, academic health center, or physician group, thereby giving consumers “a false sense of trust in the quality and appropriateness of [the] services provided,” regardless of whether testing is truly indicated. Moreover, little evidence exists to show that patients change unhealthy behaviors, such as smoking, based on the results of a commercial test, the authors contend.

The authors maintain that “promoting and selling nonbeneficial testing violates the ethical principles of beneficence and nonmaleficence as set forth in the sixth edition of the ACP’s Ethics Manual. At a minimum, they say, the companies offering direct-to-consumer screening need to state for whom their tests are indicated based on published, evidence-based guidelines, and they should inform customers of the risks of positive or negative test results before performing tests. Similarly, the authors say, medical organizations, hospitals, and doctors should not sponsor screenings with commercial companies that offer unproven or harmful testing.

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