Is medical liability reason enough to continue a low value practice?

The family medicine residency inpatient service that I supervise admitted several patients from the emergency department with acute chest pain that had resolved. Most of them had no history of cardiovascular disease, but were deemed to have enough risk factors to undergo pre-discharge cardiac stress testing after they had “ruled out” for acute coronary syndrome with normal cardiac enzymes.

Rationales for the American Heart Association’s recommendation for routine stress testing in patients with resolved chest pain include reducing malpractice liability, improving cardiac risk stratification, and initiating appropriate interventions earlier in high-risk patients. Although this practice is widely accepted, there is no evidence that it improves patient-oriented outcomes compared to outpatient management, and some researchers have argued that randomized trials are needed to prove that the benefits actually exceed the harms.

A recent study published in JAMA Internal Medicine adds fuel to this debate by presenting prospectively collected outcomes of adult patients evaluated in the emergency department chest pain unit of Mount Sinai Medical Center from 2004 to 2010. A total of 4181 patients underwent stress testing (512 with exercise ECG tests and the rest with nuclear perfusion imaging), and 470 tests suggested potential myocardial ischemia. 123 patients underwent cardiac catheterizations; 60 of these patients were found to have normal coronary arteries. Of the 63 patients whose catheterizations showed obstructive coronary artery disease, only 28 had lesions that warranted stenting or coronary artery bypass grafting according to expert consensus guidelines.

There are at least two ways to view this study’s results. A positive interpretation is that cardiac stress testing led to in the presumptive diagnosis of coronary artery disease in more than 10 percent of patients, who could then have received medical interventions shown to improve outcomes.

On the other hand, the high false positive rates on coronary angiography suggest that up to half of these diagnoses were incorrect (and, consequently, that more than 150 patients would have received therapy inappropriately). Nearly 90 percent of patients were exposed to significant radiation doses through nuclear imaging, but less than 1 percent had coronary artery lesions that warranted revascularization.

So are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • buzzkillerjsmith

    Cost-benefit analysis in medicine is quite subjective, so the answer to your first question is who the heck knows.

    Reducing liability risk is an important goal. If docs get sued enough they leave or burn out or limit important interventions. I knew a good neurosurgeon in southern Oregon who stopped taking trauma call because of the liability risk. Interstate 5 trauma cases had to be helicoptered out.

    Not doing this test might become standard of care if we docs decide it should be so based on the evidence. If it becomes standard of care then not doing the test would reasonable. It might already be reasonable from an evidence-based standpoint, but scientific evidence only gets us so far in this society. Sad but true. Avoiding doing the workup now is playing with fire.

    • ninguem

      Do they still have head trauma service in Southern Oregon? I’d heard they were one neurosurgeon away from closing, meaning lose one more neurosurgeon and they’d close.

      The neurosurgeons were moving their practices to smaller hospitals, allowing them to limit themselves to spine work and making it geographically prohibitive to take ER call (sorry, can’t go to Medford for that skull fracture because I’m doing a spine surgery in Ashland, so ship to Portland).

      Or so I’d heard, but I don’t know as much about that part of the state.

      • buzzkillerjsmith

        Not sure about Medford. I left in 2005 and it was actually at Mercy in Roseburg where the guy quit taking call. BTW, never work in Roseburg. Don’t even visit. Just keep your eyes on the road until you’re out of town.

        • ninguem

          Wasn’t John Kitzhaber in Roseburg about fifteen years?

          • buzzkillerjsmith

            I think so but he left before I got there. Good move on his part.

    • Margalit Gur-Arie

      Quick question for the uninitiated: is there another, better, way to identify those 28 people in time to help them? Or are we saying that 28 people out of 4181, over 6-7 years, is an acceptable loss ratio?

      • buzzkillerjsmith

        I think they’re saying it is an acceptable missed diagnosis ratio, but I would invite any cardiologist on this thread to correct me if that is required. I also don’t think there is a good alternative in terms of diagnosis.

        An interesting and important question is what would happen to folks in the same situation as the 28. How many would have their problem diagnosed soon anyway without ill effect, how many would die of MI, how many would suffer a significant MI with its subsequent problems?

  • Shirie Leng, MD

    This is always a difficult question. As buzz knows, I’m generally a less-is-more kind of gal, but it you’re the 1 percent in this case you’re pretty happy. I think the larger question is one that this nation struggles with all the time: the good of the many vs. the good of the one. If you decide on the good of the many, healthcare costs go way down. If you decide on the good of the one, it’s expensive but you might save a few people whom you wouldn’t otherwise. That’s not a hard sell for a doctor. We’re trained to save those few people. That’s why the whole discussion of healthcare spending is so difficult.

  • Steven Reznick

    I think until we come up with a better scheme for identifying those individuals with significant disease AND we grant some form of liability immunity to the caregivers and institutions following agreed upon future evidence based guidelines then the practice will continue. We have a professional responsibility to identify and treat those individuals with real significant disease. The cost factor is an economic issue and an ethics issue that can be debated until hell freezes over about what is an acceptable loss ratio? If its your loved one that number is zero.

  • Doctor Nick

    Looks like some of my colleagues need to think about risk/benefit a little more. The only consideration of these testing regimens is not cost!

    470 people were supposedly identified with coronary disease. Of those, 123 had caths. Of the 123, 60 had normal coronaries. What happened to the other 347 people? Are they now on maximum medical therapy? Is there no risk associated with maximum medical therapy? There certainly is, and the results of cath suggest that probably at least half of those people being treated don’t need. Don’t forget that catheterization itself is not a benign procedure.

    It’s not just cost, it’s the knock on effect of all the extra testing, worry and care that ends up being unnecessary.

  • drjoekosterich

    False positives remain a big issue with screening tests. Sadly their benefits are oversold and the risks ignored. Also people end up being so relieved not to have what they never had that they do not complain.

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