Too Many Tests?

Are you one of those people who go to your doctor with not only an idea of what’s wrong with you, but a list of tests you think you should have to confirm your suspicions?  It won’t surprise anyone who listens to PodMed or watches our YouTube to learn that I AM one of those people.  But a study in this week’s Annals of Internal Medicine may soon limit medical testing for all of us.  The study surveyed internal medicine physicians and asked them to identify so called “low value” tests.  “Low value” meant tests that were unlikely to change clinical management of the patient or may result in even more testing.  Surprise!  The list is 37 items long and contains things like routine EKGs or stress tests in people who are at low risk for heart disease, screening for Lyme disease in people without symptoms, and imaging of all types for low back pain. Identifying "low value" testing will hopefully help physicians to focus instead on "high value, cost-conscious" care, the authors say.  Such tests instead provide additional, clinically relevant information with an eye toward cost containment. 

Some rather startling statistics underpin this impetus for this study:  US healthcare costs have risen from $253 billion in 1980 to $2.2 trillion in 2008!  This is clearly unsustainable, and the authors finger medical tests, procedures, devices, and drugs as big drivers in the increase.  Many medical tests are ordered for rather insupportable reasons, including CYA medicine but also patient request.  Both Rick and the American College of Physicians indicate that very often, patients come to their appointments with at least one but more often several tests in mind that they insist upon having.  Rick confides that if he refuses such a request, he's often been informed that his patient will simply go elsewhere until he finds a willing physician, and clearly one who is more competent (!).

The paper suggests that physicians must query themselves when they're considering ordering any test: will the results of this test change clinical management? What is the likelihood of a false positive test? And what are the true costs of the test, including consequences of testing such as additional screening or procedures? are some of them.  Clearly, this new paradigm for testing attempts to use an evidence base to inform such ordering.

Another issue illustrated by this paper is that of patient expectation.  As I quip in the YouTube, maybe the next physician visit will not only result in no antibiotic prescription but no order for an X-ray for low back pain.  As consumers of healthcare, we need to shift our thinking as well and accept that sometimes, no intervention is best for all concerned.

Other topics this week include the appropriate interval for osteoporosis screening in NEJM, national obesity trends in JAMA, and the dangers of sleep apnea in women, also in Annals.  Until next week, y'all live well.

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