By LEE BOWMAN
Scripps Howard News Service
May 23, 2006
A review of medical data from more than 4,600 Americans over age 20 found that diagnostic tests not recommended under professional guidelines, or even advised against, were ordered for more than a third of the patients.
Such tests frequently produce false-positive results that led to still more tests that drive up expense and patient anxiety, said Dr. Dan Merenstein, an assistant professor of family medicine at Georgetown University Medical Center in Washington and lead author of the study. It appeared Friday in the June issue of the American Journal of Preventive Medicine.
"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," Merenstein said.
"More is not always better, and understanding this is especially important now that Medicare has begun to reimburse for complete physicals."
As a benchmark of usefulness, the researchers from Georgetown and Johns Hopkins University in Baltimore relied on standards issued by the U.S. Preventive Services Task Force. That panel of experts grades screening measures using the latest scientific evidence of effectiveness.
The researchers focused on "C" tests, those for which the panel has made no recommendation in patients who don't have symptoms that suggest a test might be helpful, and "D" tests, which the task force recommends against for patients without any symptoms, since the risks outweigh benefits.
After examining patient records from the National Ambulatory Medical Care Survey, an annual government look at patient care provided in doctor's offices, the researchers then looked to see how many of the "D" class of tests had been ordered, specifically urinalysis, electrocardiogram (EKG) and X-rays, in patients for whom they were medically inappropriate.
The researchers found that at least one of the three exams was inappropriately ordered in 43 percent to 46 percent of the patients.
Projecting that level of use across the U.S. population, the researchers estimated that the annual direct medical costs from inappropriate use of just those three tests ranged between $47 million and $194 million.
Adding tests in the "C" class -two kinds of blood-screening procedures - the researchers found additional un-recommended use, adding another $12 million to $63 million a year to the national medical bill.
What the direct spending failed to capture, the researchers noted, were the extra costs that arise when the first round of tests produced false-positives - wrongly showing evidence of a health problem - but prompted further needless tests.
For instance, other studies showed that 20 percent to 30 percent of EKGs result in a false positive that indicates irregular heart activity, and patients with such results almost always have follow-up exams, Merenstein said.
"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 the patient feels, the time off from work they have to take, and the possible complications that result from the follow-up test."
The study found that improper tests were ordered more often for men than for women and for Hispanic patients more often than for non-Hispanics.
Merenstein and his co-authors, Drs. Neil Powe and Gail Daumit of Hopkins, cited possible reasons for the testing excess, including:
- Physicians may not be aware of the guidelines for use of tests;
- Doctors may be ordering the tests to protect themselves against malpractice suits;
- Some physicians may be driven by financial incentives to order the tests, particularly if their office includes a lab or has links to a diagnostic facility.
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