Diagnostic Testing: Finding the Right Balance

By Jennifer Larson, contributor

August 8, 2013 - How much diagnostic testing is too much? How much of a role should cost play when it comes to deciding about diagnostic testing and screening? Does fear of litigation influence how much diagnostic testing a provider orders?

These questions and more are on the minds of many healthcare leaders and providers, as they try to achieve the optimal balance that will preserve the health of their patients without breaking the bank.

A few examples of the ongoing discussion over the best use of diagnostic testing:

• In 2012, a group of nine medical specialty boards issued a joint recommendation that health care practitioners address the issue of overuse by reducing their rate of ordering 45 common tests and procedures. They also announced the launch of the Choosing Wisely initiative, which is led by the ABIM Foundation, to promote the more effective use of health care resources.
• Thirty-five specialty organizations have joined the Choosing Wisely campaign, which promotes the development of evidence-based lists of tests and procedures with the goal of improving outcomes while also avoiding unnecessary care and reducing costs.
• Coming this September, the Dartmouth Institute for Health Policy and Clinical Practice will hold a conference to address the issue of overdiagnosis and strategies to prevent it.

A number of recent studies and articles have looked at the issue of diagnostic testing from various perspectives---and suggest that policy changes could make a difference.

A recent Viewpoints column for the Journal of the American Medical Association (JAMA) noted the growing concern over the value of early detection and removal of certain types of cancer. While clinicians do not intentionally set out to overdiagnose or overtreat cancer, early screening tests often catch slow-growing, or indolent, tumors. With these particular types of cancers, early detection often results in overtreatment.

The National Cancer Institute met last year to discuss the issue of cancer overdiagnosis. Ideally, the Viewpoint authors wrote, improvements in the understanding of the biology of the cancers will contribute to the development of better screening interventions. In the meantime, an NCI task force recommended some strategies to improve the current approach to cancer screening and prevention. 

“Policies that prevent or reduce the chance of overdiagnosis and avoid overtreatment are needed, while maintaining those gains by which early detection is a major contributor to decreasing mortality and locally advanced disease,” wrote Laura Esserman, MD, Ian Thompson Jr., MD, and Brian Reid, MD, PhD.

Meanwhile, a study published online for the journal Pediatrics in July suggests that higher rates of diagnostic testing don’t always result in better outcomes.

The researchers found that a higher rate of diagnostic testing for pediatric pneumonia in the emergency department tends to lead to higher hospitalization rates--but not a higher rate of ED revisits. This suggests that sometimes certain diagnostic tests might not be as necessary as some may think. For example, two of the tests that the researchers examined were the CBC and inflammatory markers.

“These are tests that the literature has really established do not substantively change the outcome with children in pneumonia, yet they were the highest obtained tests in our data set,” said Todd Florin, MD, the study’s lead author.

The authors wrote that the data suggests that hospitals with a high rate of diagnostic test utilization for community-acquired pneumonia could possibly decrease their test utilization and hospitalization “without overlooking children who warrant hospital admission.”

“I do think that higher-utilizing hospitals do need to reexamine why their utilization rates are so high and then look at their outcomes and see if their utilization is changing patient outcomes,” said Florin.

Florin noted that the culture of some healthcare institutions may play a role in the higher rate of diagnostic test utilization. But could fear also propel some physicians and providers to order more tests?

A study published in the August issue of Health Affairs discussed the relationship between physicians’ fear of malpractice suits and the likelihood that they would order more diagnostic tests for their patients.

While the study doesn’t necessarily answer the question of what should be done to address the practice of defensive medicine, it does raise some issues. 

Essentially, the researchers found that patients who were seen by a physician who had expressed a higher level of concern over malpractice liability were more likely to get certain studies or tests, like MRIs or CT scans. The study examined the use of services for treating patients complaining of back pain, chest pain, or headache.

And the Center for Studying Health System Change (HSC) research team noted that the presence or absence of common malpractice tort reforms that have been adopted by some states, such as caps on damages, didn’t seem to make much of a difference.

“The presence of those tort reforms doesn’t really seem to be associated with lower rates of defensive behavior,” noted study co-author Emily Carrier, MD, a senior researcher with HSC.

Carrier and the other researchers wrote, “Policy approaches that target the underlying causes of physicians’ malpractice concerns might reduce defensive medicine more effectively than current estimates suggest.” They also suggested that it could be useful to better educate physicians about the realities of the malpractice claims process and their actual versus perceived risk of being sued.

There are some ongoing pilot programs that hold promise--notably the “safe harbor” initiatives that would offer legal protection to practitioners who follow evidence-based guidelines that have been developed by various professional organizations.

“But it’s too early to know if they’re successful or not,” said Carrier.

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