Unnecessary Medical Tests
An article from 'Science Daily' entitled 'Millions Squandered In Unnecessary Tests Ordered In Routine Doctor Visits' focuses on an issue whose importance is very much underestimated. The article in italics and my comments in standard print follow.
Unnecessary medical tests are costing the U.S. health care system millions--and potentially billions-- of dollars per year, and add unnecessary patient stress, say researchers from Georgetown University Medical Center and Johns Hopkins University in the June issue of the American Journal of Preventive Medicine.
Not only are the tests unwarranted, but false-positive results lead to further tests and compound the expense, says the study's lead author, Dan Merenstein, MD, an assistant professor in the Department of Family Medicine at Georgetown.
This is one of many unfortunate side effects of unnecessary tests. The considerable costs and added patient stress were already alluded to. False positives are an unavoidable consequence of testing. Much effort is made to minimize them but no testing system is perfect. When tests are wisely ordered false positives can be accepted as an inevitable fact of life. When superfluous tests are ordered, any false positives resulting in further unnecessary costs, tests or even treatment, compound the problem.
"Many physicians, as well as their patients, appear to believe that a routine health exam should include a number of tests they feel can screen for unknown diseases, but the evidence shows that some of these tests are less than beneficial when used in this way," he said. "More is not always better, and understanding this is especially important now that Medicare has begun to reimburse complete physicals."
The study looked at recommendations of the United States Preventive Services Task Force (USPSTF), a panel of experts that grades preventive screening measures based on evidence of their effectiveness. The researchers focused on "C" and "D" tests to see how often they were being used in routine patient visits. In asymptomatic patients, a "C" test are those tests the panel made no recommendation for use. "D" tests, are those which the panel recommended against as risks outweigh the benefits.
These "C" and "D" procedures fell into two categories: "interventions"--this includes an electrocardiogram (EKG) that records heart activity and X-rays and procedures that are analyzed in a laboratory: a urinalysis; a hematocrit which measures volume of red blood cells in blood; and a complete blood count, or CBC, which measures red and white blood cells and platelets, in blood.
To conduct the study, the researchers reviewed data from the National Ambulatory Medical Care Survey (NAMCS) sponsored by the Centers for Disease Control. They analyzed 4,617 general examination visits by adults over age 20. The researchers then looked at how many of the "D" category tests -- urinalysis, EKG, and X-rays-- were ordered, and found at least one of the three D interventions was ordered 43-46% of the time.
The researchers then extrapolated their findings into a national picture of use, and estimated that annual direct medical costs for the three "D" category tests -- those whose use the panel recommended against -- ranged from $47 million to $194 million. Adding the other two tests, those in the "C'' category --urinalysis and blood tests--added an additional $12-$63 million.
What the numbers miss, however, according to researchers, are the various costs that occur when a test is false positive -- that is, wrongly shows evidence of a health problem. For example, studies show that 20-30 percent of EKG tests result in false positive results, and patients with these results usually have follow-up exams that are much more expensive, Merenstein says.
"We estimate that if 20 percent of EKGs are false, the follow-up tests will cost about $683 million, and that doesn't account for the stress that a patient feels, the time off from work they have to take, and the possible complications that result from the follow-up test."
If you think you need not be concerned with costs because insurance or Medicare is covering some or all of the expenses think again. Unnecessary costs skew effective medical care. Insurance companies and the government are not endless sources of funding. If millions are needlessly wasted there is correspondingly less available for legitimate health care. Costs always entail an associated waste of time- both for the patient and for medical care professionals as well. Time and money are limited commodities. There is no free lunch and we pay for waste one way or another. Higher insurance premiums and higher taxes are obvious effects. So too is less efficient health care.
Among their other findings is that men are given more of these tests than are women, and that Hispanics are also offered more tests than non-Hispanic patients.
Merenstein and his two co-authors say among the many reasons that diagnostic interventions which lack evidence of benefit in asymptomatic patients are used are:
Studies have shown that many patients have expectations of receiving particular tests when visiting physicians.
It is possible that physicians are ordering these tests defensively, to guard against potential lawsuits.
This is a very important point. Fear of lawsuits is probably the single greatest incentive for ordering unnecessary tests. Physicians do not want to be second guessed by an attorney questioning why a particular test was not ordered. Reputations as well as money are at stake. We do not want a system without legal remedies for malpractice. However, our tort system is frequently abused by those whose motive is greed rather than justice. Frivolous claims drive up costs and distort health care priorities.
Physicians may not be aware of USPSTF recommendations.
There may be a financial incentive to ordering these tests, especially if a physician's office includes a laboratory.
"But the fact is that less use of unwarranted interventions will likely eliminate waste and improve overall quality of healthcare in the United States," Merenstein said.
Yes indeed. The rising cost of health care over the last few decades reflects fundamental health care problems in the United States. This article and more like it are needed to focus on the problems, which when understood, suggest the right solutions.
Unnecessary medical tests are costing the U.S. health care system millions--and potentially billions-- of dollars per year, and add unnecessary patient stress, say researchers from Georgetown University Medical Center and Johns Hopkins University in the June issue of the American Journal of Preventive Medicine.
Not only are the tests unwarranted, but false-positive results lead to further tests and compound the expense, says the study's lead author, Dan Merenstein, MD, an assistant professor in the Department of Family Medicine at Georgetown.
This is one of many unfortunate side effects of unnecessary tests. The considerable costs and added patient stress were already alluded to. False positives are an unavoidable consequence of testing. Much effort is made to minimize them but no testing system is perfect. When tests are wisely ordered false positives can be accepted as an inevitable fact of life. When superfluous tests are ordered, any false positives resulting in further unnecessary costs, tests or even treatment, compound the problem.
"Many physicians, as well as their patients, appear to believe that a routine health exam should include a number of tests they feel can screen for unknown diseases, but the evidence shows that some of these tests are less than beneficial when used in this way," he said. "More is not always better, and understanding this is especially important now that Medicare has begun to reimburse complete physicals."
The study looked at recommendations of the United States Preventive Services Task Force (USPSTF), a panel of experts that grades preventive screening measures based on evidence of their effectiveness. The researchers focused on "C" and "D" tests to see how often they were being used in routine patient visits. In asymptomatic patients, a "C" test are those tests the panel made no recommendation for use. "D" tests, are those which the panel recommended against as risks outweigh the benefits.
These "C" and "D" procedures fell into two categories: "interventions"--this includes an electrocardiogram (EKG) that records heart activity and X-rays and procedures that are analyzed in a laboratory: a urinalysis; a hematocrit which measures volume of red blood cells in blood; and a complete blood count, or CBC, which measures red and white blood cells and platelets, in blood.
To conduct the study, the researchers reviewed data from the National Ambulatory Medical Care Survey (NAMCS) sponsored by the Centers for Disease Control. They analyzed 4,617 general examination visits by adults over age 20. The researchers then looked at how many of the "D" category tests -- urinalysis, EKG, and X-rays-- were ordered, and found at least one of the three D interventions was ordered 43-46% of the time.
The researchers then extrapolated their findings into a national picture of use, and estimated that annual direct medical costs for the three "D" category tests -- those whose use the panel recommended against -- ranged from $47 million to $194 million. Adding the other two tests, those in the "C'' category --urinalysis and blood tests--added an additional $12-$63 million.
What the numbers miss, however, according to researchers, are the various costs that occur when a test is false positive -- that is, wrongly shows evidence of a health problem. For example, studies show that 20-30 percent of EKG tests result in false positive results, and patients with these results usually have follow-up exams that are much more expensive, Merenstein says.
"We estimate that if 20 percent of EKGs are false, the follow-up tests will cost about $683 million, and that doesn't account for the stress that a patient feels, the time off from work they have to take, and the possible complications that result from the follow-up test."
If you think you need not be concerned with costs because insurance or Medicare is covering some or all of the expenses think again. Unnecessary costs skew effective medical care. Insurance companies and the government are not endless sources of funding. If millions are needlessly wasted there is correspondingly less available for legitimate health care. Costs always entail an associated waste of time- both for the patient and for medical care professionals as well. Time and money are limited commodities. There is no free lunch and we pay for waste one way or another. Higher insurance premiums and higher taxes are obvious effects. So too is less efficient health care.
Among their other findings is that men are given more of these tests than are women, and that Hispanics are also offered more tests than non-Hispanic patients.
Merenstein and his two co-authors say among the many reasons that diagnostic interventions which lack evidence of benefit in asymptomatic patients are used are:
Studies have shown that many patients have expectations of receiving particular tests when visiting physicians.
It is possible that physicians are ordering these tests defensively, to guard against potential lawsuits.
This is a very important point. Fear of lawsuits is probably the single greatest incentive for ordering unnecessary tests. Physicians do not want to be second guessed by an attorney questioning why a particular test was not ordered. Reputations as well as money are at stake. We do not want a system without legal remedies for malpractice. However, our tort system is frequently abused by those whose motive is greed rather than justice. Frivolous claims drive up costs and distort health care priorities.
Physicians may not be aware of USPSTF recommendations.
There may be a financial incentive to ordering these tests, especially if a physician's office includes a laboratory.
"But the fact is that less use of unwarranted interventions will likely eliminate waste and improve overall quality of healthcare in the United States," Merenstein said.
Yes indeed. The rising cost of health care over the last few decades reflects fundamental health care problems in the United States. This article and more like it are needed to focus on the problems, which when understood, suggest the right solutions.
posted by Paul at 10:20 PM
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