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Two Dartmouth Studies Report Unnecessary Testing

 |  By cclark@healthleadersmedia.com  
   November 26, 2012

Two reports issued last week by the Dartmouth Institute for Health Policy and Clinical Practice raise new questions about whether physicians order far too many tests, and whether some tests might be motivated more by economic rather than diagnostic or therapeutic reasons, whether subconsciously or not.

The first report, published in the Online First edition of Archives of Internal Medicine, points to a wide regional variation in the rate by which Medicare beneficiaries receive certain repeat tests, often with far more frequency than existing guidelines suggest they should be conducted.

For example, of the Medicare beneficiaries who underwent echocardiography within the three-year period between Jan. 1, 2004 and Dec. 31, 2006 (28.5% of the beneficiary population), nearly a third (31.1%) experienced a repeat test within a year and over half (55.2%) had a repeat test within three years.

But the percentage of retested patients varied dramatically depending on what region of the country they received care.

In Miami, for example, which had the highest rate of testing in three of six testing categories examined, 39% of patients received a repeat test within one year and 66% within three years. However, in Portland, OR, which had the lowest rate of repeat testing in three of six types of tests examined, 25.5% received a repeat echocardiogram within one year and 47.1% within three years.

The study shows a similar story for imaging stress tests. In Orlando, the one-year retest percentage was 24.2% and the three-year retest percentage was 53.8%, but in Portland, those comparative percentages were 11% and 29.8%, respectively.

The authors, led by H. Gilbert Welch, MD, a general internist at the White River Junction VA Medical Center and a Dartmouth Institute professor, said that the testing practices they examined have high-risk factors for "incidental detection and overdiagnosis." Testing above what is needed adds to costs, and may prevent other patients from getting the diagnostic workups they really should have, they said.

"Although we expected a certain fraction of examinations to be repeated, we were struck by the magnitude of that fraction: one-third to one-half of these tests are repeated within a three-year period," they wrote. "This finding raises the question whether some physicians are routinely repeating diagnostic tests."

"Tests that are routinely repeated following a brief period require that more capacity (more diagnostic equipment, such as imaging systems and more personnel) must be in place to be able to provide access for new patients," Welch and colleagues wrote, adding that "short intervals to repeat testing also raise costs."

Wide variations in pulmonary function, chest computed tomography, cystoscopy, and upper endoscopy were also found. For example, pulmonary function tests were repeated within one and three years in 39.2% and 56.6% of Medicare beneficiaries, respectively, in Detroit, but in 28.8% and 39.4% of beneficiaries in San Francisco.

Geographic variation was also observed for eye examinations and screening mammography but was less pronounced.

In an accompanying Invited Commentary in the same issue, Jerome Kassirer, MD, former editor-in-chief of the New England Journal of Medicine, and Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center at Stanford University, wrote that "financial incentives" are at the root of overtesting, "sustained by tacit intraregion physician practice norms."

"Many physicians privately acknowledge that financial reward is a major underpinning of these norms," they wrote. "When attempting to intervene, medical directors of healthcare systems or physicians' independent practice associations frequently face an underlying physician counterargument that they 'cannot afford' to cut back on current levels of resource use without an offsetting payment. Hippocrates and Osler would not be impressed."

And even though payment incentives and penalties in the Patient Protection and Affordable Care Act and other rules in recent years may discourage overtesting, they will not be enough, Kassirer and Milstein wrote.  "We will have to swallow much stronger policy medicine."

The second study, also by Welch, with Archie Bleyer, MD, of the St. Charles Health System in Portland, OR, "raises serious questions about the value of screening mammography," and asks whether women are receiving too many mammograms and too many harmful interventional procedures that were not really required.

Their report, published in the New England Journal of Medicine, estimates that in the last 30 years, more than one million women have been overdiagnosed with breast cancer, and that screening with mammography has not resulted in a reduction in late-stage metastatic cancers discovered, a benefit that should have been expected.

They acknowledge that death rates have declined, but they suggest that has more to do with better late-stage breast cancer treatments in recent years, not in increased treatment at earlier stages of disease.

"Our analysis suggests that whatever the mortality benefit, breast-cancer screening involved a substantial harm of excess detection of additional early-stage cancers that was not matched by a reduction in late-stage cancers," they wrote.

"This imbalance indicates a considerable amount of overdiagnosis involving more than 1 million women in the past three decades—and, according to our best-guess estimate, more than 70,000 women in 2008 (accounting for 31% of all breast cancers diagnosed in women 40 years of age or older)."

They argue that the benefits from mammography "are probably smaller, and the harm of overdiagnosis probably larger, than has been previously recognized."

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