Millions squandered in unnecessary tests ordered in routine doctor visits

May 19, 2006

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.

"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."

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:

The study was funded by the Robert Wood Johnson Clinical Scholars Program. Merenstein's co-authors include Neil Powe, M.D., and Gail Daumit, M.D., of Johns Hopkins University.

About Georgetown University Medical Center
Georgetown University Medical Center is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through our partnership with MedStar Health). Our mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis--or "care of the whole person." The Medical Center includes the School of Medicine and the School of Nursing and Health Studies, both nationally ranked, and the world renowned Lombardi Comprehensive Cancer Center. For more information, go to http://gumc.georgetown.edu.

Contact: Liz McDonald
eem6@georgetown.edu
202-687-5100
Georgetown University Medical Center

Millions of Dollars Wasted on Unnecessary Medical Tests: Study

These exams are typically administered during regular physicals, researchers say

By Amanda Gardner
HealthDay Reporter

FRIDAY, May 19 (HealthDay News) -- Unnecessary medical tests ordered during routine physical exams are costing the U.S. health-care system millions, if not billions, of dollars each year, a new study contends.

And with those tests comes the gratuitous stress that such exams can cause patients, the researchers said.

"Tests are ordered that aren't recommended," said study lead author Dr. Dan Merenstein, assistant professor of family medicine at Georgetown University School of Medicine.

The findings weren't a surprise to experts in the field.

"Until the system provides financial incentives to reward the use of highly valued services and penalizes for those unproven interventions, the use of these unwarranted interventions will continue," said Dr. Mark Fendrick, professor of internal medicine and of health management and policy at the University of Michigan School of Medicine.

"These types of massive screening activities are not very cost-effective generally," added Greg Scandlen, founder of Consumers for Health Care Choices. "If a patient is in an at-risk group, then this kind of screening is appropriate, but the cost of doing it to large numbers of people just to find a tiny fraction of people with a problem is not justified," he added.

Routine preventive health exams, or regular physical exams, are designed to identify diseases in their early stages and prevent other diseases from occurring. While tests can be part of these doctor's visits, it's not often clear which ones are beneficial to generally healthy people coming for a check-up.

The authors of the new study, which appears in the June issue of the American Journal of Preventive Medicine, based their study on recommendations of the United States Preventive Services Task Force, a panel of experts that ranks different preventive screening measures.

Measures are graded "A," "B," "C" or "D." Tests in the "C" category are those for which the panel has made no recommendation for use. Tests in the "D" category are those which the panel has recommended against, because risks outweigh benefits.

The study focused on three tests in the "D" category: EKG or electrocardiogram, urinalysis and chest X-ray. The researchers analyzed data on 4,617 routine physicals involving adults aged 21 and over from a national survey conducted by the U.S. Centers for Disease Control and Prevention.

At least one of the three "D" interventions was ordered 43 percent to 46 percent of the time, the researchers said.

Using extrapolation techniques, Merenstein and his colleagues determined that direct medical costs for the three "D" tests ranged from $47 million to $194 million. Adding in two other tests from the "C" category pushed the costs up by another $12 million to $63 million.

Those numbers are, in all likelihood, an underestimate, Merenstein said. The authors estimated that if 20 percent of EKG results were false, the follow-up tests would cost yet another $683 million.

And these numbers don't take into account various indirect costs, including missed work days. Nor do they reflect the psychological effects on a patient, especially the stress of getting a false-positive result, the researchers said.

"It's not just economic," Merenstein said. "There can be unintended health risks, for example, radiation from a chest X-ray. And there's a lot of stress involved if you're told you have an abnormal EKG."

The study authors didn't look specifically at why these tests were overused, but Merenstein has some theories. "Doctors could do it to appease patients or because the physicians themselves think they're supposed to do them. And, if they owned a lab, some doctors did it for financial reasons," he said.

Experts said the answer to the problem lies in an overhaul of the nation's insurance system.

"The answer to this is value-based insurance design, which gives patients and clinicians financial incentives to do those highly valued services, and financial disincentives to minimize the use of those unwarranted services," said Fendrick, who's also co-editor-in-chief of the American Journal of Managed Care. Such programs are being tried out at the University of Michigan, he said.

Scandlen added: "This is precisely the thing that consumer-driven health care can address and that third-party payment never will. It's easy enough when you go to a doctor's office, and you can say, 'I don't care what it costs, let's do it.' At that point of transaction, both patient and physician have very little in the way of reason not to perform the tests. In a consumer-driven world, the patient has every reason to question where the test is necessary."

More information

For more on prevention and good health, visit the Agency for Healthcare Quality and Research.

SOURCES: Dan Merenstein, M.D., assistant professor, family medicine, Georgetown University School of Medicine, Washington, D.C.; Mark Fendrick, M.D., professor, internal medicine and health management and policy, University of Michigan School of Medicine, Ann Arbor, and co-editor-in-chief, American Journal of Managed Care; Greg Scandlen, founder, Consumers for Health Care Choices, Hagerstown, Md.; June 2006, American Journal of Preventive Medicine

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