What to do about too many medical tests

Amir Qaseem
Amir Qaseem
Posted: February 01, 2012

As I prepared to leave the doctor's office after a routine checkup a few months ago, the receptionist handed me a list of blood work for my next visit. I asked whether a PSA was really necessary: My prostate numbers had been elevated after six months on supplemental testosterone, but since I had stopped the hormone, two consecutive tests had come back normal.

"Your insurance will probably cover it," she said. I wanted her to question the doctor anyway, and a couple of days later, she called to say that he had removed the test.

My insurance company saved $489. More important, I avoided an unnecessary test - although I still didn't know my doctor's reasoning either way.

Spending on health care in 2008 in the United States accounted for an estimated 16 percent of gross domestic product - $2.2 trillion, or $7,681 per person - and is continuing to rise. Researchers say that up to 30 percent of the total is due to overuse of drugs, tests, and treatments.

To begin attacking this complex problem, a group of physicians has proposed a simple solution: Talk before you test.

"What are the benefits? What are the harms . . . and once you get the results, are they going to change the management of this condition in any way?" said Amir Qaseem, lead author of an article last month in the Annals of Internal Medicine that challenges doctors and patients to think differently.

The article identified 37 situations in which a test did not reflect "high-value" care, meaning that evidence has shown that it would not help and might even cause harm. Think of it as changing the oil in your car every week: It wouldn't make the engine run better, yet all those changes make an error more likely.

Qaseem, who is clinical policy director for the American College of Physicians in Philadelphia, said he couldn't tell, without more medical information, whether my own example of the prostate screening was unnecessary. The 37 situations identified in the paper were very specific, based on evidence and chosen by consensus of the 11 authors.

Getting an MRI for nonspecific lower-back pain is one of them. First, the scan is unnecessary, Qaseem said - 85 percent of cases are caused by a strain that heals with exercise and medication. Second, the test result will not change the treatment. Third, abnormalities that cause no problems often show up on back scans, leading to more tests and sometimes surgery, which raises not just the cost, but the likelihood of injury.

Doctors sometimes order unnecessary tests - just as they prescribe antibiotics to children who clearly have a virus that will not respond to those drugs - because patients (or their parents) want the doctors to "do something."

A "yes" is easily written; a "no" requires a conversation.

Darilyn V. Moyer, an internal-medicine doctor at Temple University and one of the paper's authors, said that when her patients have wanted a test that she has described as not necessary, she has pushed to find out the source of their belief. "Who in the family? Who in the social network?" she said.

"It does take a lot of time."

Which is an issue: Physicians in managed-care practices say they must see so many patients that their time is limited. Fee-for-service plans reimburse doctors for specific actions, not for talk.

"It is a problem," agreed Lonny Reisman, chief medical officer for Aetna.

Overuse of tests, which clearly costs the giant insurer - and ultimately employers - bundles of money (he did not have a tally), is one reason that Reisman said he supported "fundamentally realigning" payment mechanisms in ways that, for example, reward doctors for their patients' progress rather than for ordering more tests.

Economists say skyrocketing health-care costs have held down wages for everyone for years. What can an ordinary person do?

"As a patient," Qaseem said, "you need to ask questions of your physician."

37 Scenarios

Researchers identified 37 scenarios when commonly ordered medical tests do no good and may even cause harm. Cost was not considered. Value - the extent to which benefits outweigh harms - was the key.

But patients are encouraged to go beyond this list and ask questions (see below) about any ordered test.

The following are in no particular order:

  1. Repeating screening ultrasonography for abdominal aortic aneurysm following a negative study.
  2. Performing coronary angiography in patients with chronic stable angina with well-controlled symptoms on medical therapy or who lack specific high-risk criteria on exercise testing.
  3. Performing echocardiography in asymptomatic patients with innocent-sounding heart murmurs, most typically grade I-II/VI short systolic, midpeaking murmurs that are audible along the left sternal border.
  4. Performing routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3-5 years.
  5. Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function.
  6. Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease.
  7. Obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults.
  8. Performing an imaging stress test (echocardiographic or nuclear) as the initial diagnostic test in patients with known or suspected coronary artery disease who are able to exercise and have no resting electrocardiographic abnormalities that may interfere with interpretation of test results.
  9. Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure.
  10. Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles.
  11. Using MRI rather than mammography as the breast cancer screening test of choice for average-risk women.
  12. In asymptomatic women with previously treated breast cancer, performing follow-up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging.
  13. Performing dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 y in the absence of risk factors.
  14. Screening low-risk individuals for hepatitis B virus infection.
  15. Screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease.
  16. Screening for colorectal cancer in adults older than 75 years or in adults with a life expectancy of less than 10 years.
  17. Repeating colonoscopy within 5 years of an index colonoscopy in asymptomatic patients found to have low-risk adenomas.
  18. Screening for prostate cancer in men older than 75 years or with a life expectancy of less than 10 years.
  19. Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk.
  20. Performing imaging studies in patients with nonspecific low back pain.
  21. Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
  22. Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery.
  23. Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding.
  24. Performing serologic testing for suspected early Lyme disease.
  25. Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease.
  26. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes.
  27. Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination.
  28. Performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination.
  29. Routinely performing echocardiography in the evaluation of syncope, unless the history, physical examination, and electrocardiogram do not provide a diagnosis or underlying heart disease is suspected.
  30. Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery.
  31. Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features.
  32. Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism.
  33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation-perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism.
  34. Performing follow-up imaging studies for incidentally discovered pulmonary nodules 4 mm in low-risk individuals.
  35. Monitoring patients with asthma or chronic obstructive pulmonary disease by using full pulmonary function testing that includes lung volumes and diffusing capacity, rather than spirometry alone (or peak expiratory flow rate monitoring in asthma).
  36. Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia.
  37. Screening for chronic obstructive pulmonary disease with spirometry in individuals without respiratory symptoms.

SOURCE: Ideas and Opinions: "Appropriate Use of Screning and Diagnostic Tests to Foster High-Value, Cost-Conscious Care," by Amir Qaseem, et. al.,  Annals of Internal Medicine

Questions Physicians Should Ask Themselves* Before Ordering Tests

* And patients may want to ask their doctors when tests are ordered.

  1. Did the patient have this test previously? If so, why repeat it? Is the result likely to be significantly different?
  2. Will the test  result change my care of the patient?
  3. What are the probability and potential adverse consequences of a false-positive result?
  4. Is the patient in potential danger over the short term if I do not perform this test?
  5. Am I ordering the test primarily because the patient wants it or to reassure the patient? If so, have I discussed the above issues with the patient? Are there other strategies to reassure the patient?

SOURCE: Editorial: "High-Value Testing Begins with a Few Simple Questions," by Christine Laine, Annals of Internal Medicine

Contact staff writer Don Sapatkin at 215-854-2617 or dsapatkin@phillynews.com.

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