Test overuse: Why does it happen and what can we do about it?

In medicine today diagnostic testing and advanced imaging is readily available and widely utilized in most every clinical setting.  Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan.  Fear of missing something pervades every emergency department and has resulted in hundreds of thousands of unnecessary testing costing billions of dollars in healthcare expenditures.

Of course, the driving causes of increased testing and utilization of advanced imaging are numerous and complex.  Unfortunately, in my experience, the two most common reasons are fear of malpractice litigation and a desire for greater reimbursement.

How do we best determine when to test?

The most basic testing techniques rely on Bayesian statistics – the question to be answered must be well defined and then a clinician must determine a pre-test probability of the presence (or absence) of the disease in question.  The best utilization of a diagnostic test is when a clinician has an intermediate pre-test probability that a particular disease state is present.

If the pre-test probability is low, then there is no need to test.  If the pre-test probability is high, then the clinician should proceed with treatment rather than an additional testing step.

In the case of coronary artery disease, if you have a patient with multiple risk factors and symptoms that are a bit atypical, diagnostic testing with a stress test with imaging makes sense.  If you have a young person with no risk factors, and very atypical symptoms diagnostic testing does not.  In contrast, if you have a patient with classic angina, an abnormal EKG and multiple risk factors you may want to forgo diagnostic imaging and proceed directly to cardiac catheterization.

What are the risks associated with radiation?

In a recent New York Times column, the authors argue that the over utilization of CT scans and other radiation based diagnostic testing results in a significant increased risk for certain types of cancers.  I tend to agree.  The radiation exposure associated with one CT scan is equivalent to more than 500 plain chest x-rays.  The FDA estimates that a patient’s lifetime risk of developing cancer from radiation exposure to a CT scan approaches 1 in 2000.  To place this all in perspective, the survivors of the atomic blasts in Japan were exposed to the equivalent radiation to two CT scans!

In addition to CT scans, nuclear medicine based stress testing in cardiology also exposes patients to large doses of radiation (even more than CT).  These tests are recommended at particular intervals by the American College of Cardiology in patients with known coronary artery disease (CAD) or in cases with suspected CAD with appropriate risk factors and baseline characteristics.  However, just as with CT scans, these imaging tests are often over-prescribed and overused.

What are the root causes for the overuse of diagnostic testing?

Much of the over-testing seen in the US is due to fear of litigation.  Doctors, as a whole, want to do their very best for patients.  When the encounter a patient with a complaint that seems routine, many astute clinicians also think about more serious diagnoses when formulating a differential.  Anecdotes from colleagues where a particular serious diagnosis was “missed” can often lead to unnecessary testing.

Moreover, the trial lawyers and “ambulance chasers” are an ever present thought for many clinicians.  The fear of being sued for missing a lung tumor in an asymptomatic patient can also lead to more unnecessary and non indicated testing.  This phenomenon is yet another important reason that we must pursue tort reform in the US today.

Unfortunately, another reason for overuse of CT scanning and other types of imaging is profit.  Profit and finances have no place in the clinical evaluation of a patient — however, economic realities have blurred these lines considerably in the last decade.  There are some clinicians that put reimbursement ahead of patient welfare.  Abuses such as routine, non indicated imaging for cardiac patients has been declining.  New guidelines and more government and regulatory scrutiny into these types of exams seems to be having a positive effect on reducing unnecessary radiation exposures.

What can we do to advocate for ourselves and our patients?

As a patient, it is essential that you ask your clinician precisely why the test is being ordered and exactly what impact the result will have on your clinical management.  As physicians we must have very clear reasons (and well documented reasons) for ordering tests.  Tests should remain an adjunct to history and physical exam for the diagnosis of disease–not a replacement for clinical experience and expertise.

So, next time you order a test (or your doctor orders a test for you) make sure you take time to understand how the exam is going to impact your course of treatment — if you are at a fork in the road, the best test should determine whether you take the road to the right or the left.

If you and your doctor already know which way to go, the test may only be another chance to “glow in the dark …”

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • Patient Kit

    As a patient, I increasingly feel caught between wondering (a) whether the insurance company is denying necessary tests to save money and (b) whether doctors are ordering unnecessary tests to make money and/or CTA. I still trust my particular doctors way more than I ever trusted insurance. But new docs and docs in general? I don’t know anymore. I want to be able to trust doctors. But things like the Choosing Wisely campaign that lists 100+ very commonly done tests as unnecessary is making it harder for us patients to sort out the competing agendas.

  • Thomas D Guastavino

    The litigation problem is so obvious at this point that it should not even be included under the heading of “unneccsary testing”. Until there is meaningful tort reform physicians will, nay, they have the right, to continue to do this as a simple matter of self preservation.
    Now, this is likely to generate a lot of controversary, but a big reason I see for unnecessary testing is primaries ordering tests not understanding what tests may be best for that patients particular problem. Some Examples:
    1) MRI scans for patients with knee pain when plain X-Ray would do.
    2) Basic X-Rays ordered when different and sometimes unusual views are needed.
    3) After an injury, primaries starting treatment on the basis of a negative X-ray report when in fact there was fracture that was missed.
    These are the common ones I see. I have seen many other cases like this.
    I know this is blasphemy to say this, but a good way to prevent unnecessary testing might just be getting the patient to the specialist sooner then later.

    • goonerdoc

      That would be great doc. Just have primaries be clearinghouses for their patients. We wouldn’t even have to think at all! Knee pain? Ortho! Earache? Please see our ENT doc! Sinusitis? Time for an ID consult! Do you have so little regard for primary care that you actually believe what you just said?

      • Thomas D Guastavino

        Exactly the reaction I expected. The point of the post was to identify possible causes of unnecessary testing. Is it not our goal, nay are obligation to do the most appropriate tests that best serves our patients? Say a patient presents to me leg pain and swelling. I suspect a DVT. Since I am very familiar with the appropriate testing I would have no problem proceeding with the test and if positive, refer the patient back to their primary for treatment. Say, however, a patient presents presents to me with chest pain. Since I am very unfamiliar with the appropriate testing an immediate referal to an ER or the patients primary would be appropriate.
        If we dont police ourselves someone else is going to do it.

        • goonerdoc

          Sorry Doc, you’re reasoning doesn’t fly. It’s all good when you, as a specialist, has the benefit of the retrospectoscope and can see where the lowly primary missed the diagnosis. “How could they have missed this fracture…it’s SO obvious on the MRI!” We deal with generalities most often (chest pain, sinus pressure) whereas you have the luxury of dealing with specific diagnoses (bucket handle meniscus tear, tibial plateau fracture, etc.) It’s a lot easier when you have half of the workup completed already to second guess the referring physician. And yes, I believe we absolutely have the obligation to best serve our patients, but that doesn’t mean sending them to a specialist at the first opportunity. Do I refer when I need help? Absolutely. Do I have the ability to develop a differential diagnosis and do appropriate testing before referral? You bet I do. I’m sorry you have such little faith in the primary physicians in your area.

          • Thomas D Guastavino

            Sorry doc, I am not talking about standing on top of the train, I am talking about going down the wrong track to begin with. The first three are real life examples of patients I have seen repetitively that were sent by there primary for an MRI before anything else was done. The last happens quite often.
            1) 24 yo male, twisting injury to knee , c/o painful, swelling and locking. Procedure: Aspiration of knee followed by injection to unlock, then an MRI for torn meniscus or ACL
            2) 17 yo female , no injury, c/o anterior knee pain and popping. Exam shows pain on patellar balottement with positive apprehension sign. Procedure: Standing AP knee X-Ray with patellar views, possible CT scan and therapy for patellar subluxation.
            3) 72 yo male, c/o slow onset pain right knee pain, occasional swelling, no cracking or popping. Procedure: Plain standing AP knee X-Rays followed by treatment for osteoarthritis.
            4) 45 yo male, fall on wrist c/o pain and swelling. Primary sends for plain X-Ray, read as negative, sends patient for PT. After 4 weeks patient is still c/o pain so refers. Exam, repeat X-Ray and review of original X-Ray shows fracture scaphoid. Patient threatens to sue.

          • rbthe4th2

            Just an FYI, my former primary tried to get an MRI approved by insurance. Nope. Sent to specialist, it got approved. Might be the difference …

          • Thomas D Guastavino

            You might just see a lot more of this happening in the future

  • whoknows

    Here is another similar example of excess. I required a cream from a compound pharmacy. 30 grams was $300. i required 240 g. So the pharmacist said that since my insurance did not cover more than $300 per prescription, which he said was not adequate, he would bill the insurance every 5 days to get $1800. but the good news for me he tells me is I don’t owe a thing! Great news. A thief: but all completely legal! BTW this cream I was told was cheap to actually make.
    I know this blog focuses on physician excess, but honestly, that has been the problem all along. You get blamed for the excesses when that is not exactly where the full problem lies-doubt if even half of the excesses lie.

    • rbthe4th2

      That’s a half and half. I’ve had BMP’s and CBC’s w/differential repeated the same night after night, but the more useful CMP was never done. Go figure …

  • Docsicle

    I was taught in residency that diagnosis is 80% history, 15% physical exam and 5% testing. One problem I see is, that patients consistently want more than the 5% testing, and are not impressed by treating via the other 95%. If a test wasn’t ordered, the doc wasn’t doing anything, right?

    • rbthe4th2

      Depends. If I ask for one blood test and they order a whole panel, what’s the point? The one blood test I asked for would more pinpoint an issue that I had before, where we used one test only. They just keep rerunning the same set of (somewhat) useless tests.

      • Suzi Q 38

        Some doctors duplicate tests.
        I have had MRI’s done at one hospital.
        When I went to get a second opinion at another hospital, the 2nd neurologist and neurosurgeon wanted me to repeat ALL the tests. I couldn’t believe it, as the previous tests were only a month old. I had to do it as that was what they required.
        When I questioned the request for a repeat MRI of the cervical thoracic and lumbar areas, the neurosurgeon told me that the previous ones were not clear……not sure about that. I think he wanted to get more revenue for his hospital.
        I needed the surgery, so I didn’t have the spirit or the time to argue.
        After the surgery, the MS department wanted me to take MS drugs when my tests all were negative for MS. I told them that I would do so if I had MS for sure. Since my tests were all negative, and the surgery improved my neck and back pain, I was not up for going through another workup, tests, and MS drugs.

        I said that I would patiently wait for future physical manifestations of such. Until then, I would think that I did not have it.

    • NYC Patient

      It’s not about wanting more testing. I don’t think anyone who is sane wants more testing (whether it’s labs, imaging, and more invasive tests).

      As one who has went through hell, the only thing I have come to ask is something. Less is more but something is not nothing when you are the type of person that typically waits months before going to see a doctor….

      If less doesn’t address symptoms (especially when they are life altering symptoms including bladder issues, weakness, balance, severe sleep deprivation, etc.) more needs to be done – even if a little at a time. The issue is that there is usually a “set plan of tests” a provider typically does. If they come back negative, too often docs (whether it’s them per se or the health systems they are a part of) shrug their shoulders and think if it’s not bad enough to come up on the initial tests, so nothing else needs to be done and wash their hands so to speak.

    • Suzi Q 38

      It depends on the patient.
      I would like more than 5%, but less than 25% testing.
      The doctors that I am seeing the last year ordered too much testing, and the first neurologist did not want much testing at all.
      I agree that it would be a difficult decision.

  • medicontheedge

    In my personal experience, I see the delivery of care in the ED, where much of these “unnecessary” tests are ordered, often over and over again on the same “customer”, are a direct result of marketing how great we are. We have to find SOMETHING to justify, in at least the customers mind, a reason for the visit. So, we test till we find something.

    • Suzi Q 38

      How sad.

  • Suzi Q 38

    Test overuse: Why does it happen?

    Take your pick: Conscientious physicians, careful physicians concerned about malpractice, or physicians who like to boost up the “bottom line” and charge more to the insurance. Their hospital/clinic pressures them to order as many tests as possible.

    What can we do about it?
    I am not sure, but the patient can say something.

    Maybe: “I am sorry, but I am not sure a full, 3 part MRI of my entire spine (cervical, thoracic, and lumbar) is necessary. I need to be careful with my insurance, as I have not met my deductible yet. My neurologist suggested that I just get MRI’s of my brain and cervical (neck) areas.”

    Here is another:
    “I just took a series of lab tests last month with my PCP. Here is a copy.”

    “No, I do not wish to get the workup and tests for Lynch’s syndrome.”

    “No, I don’t want to go to a PT specialist if h/she is only going to give me exercises that I can do at the gym or at home.”

    • rbthe4th2

      Now here is what I got when I said I couldn’t afford a visit or had problems with paying for prescriptions: a dismissal letter.
      Can prove it, even though the group in charge of this place advertises they don’t dismiss for $$$.
      Randy

      • Suzi Q 38

        I am sorry that this happens, but I am not surprised.

        You can go to a free clinic, maybe they have more drug samples. The visits are usually free.
        The problem is that you have to wait a long time to finally get to see the doctor.

  • Chris, MD

    I would certainly recommend for patients to ask their clinician why a test is being ordered and what the impact might be. This makes sense for a scan or radiation therapy, but I can’t see many patients asking their physicians to go though all the different blood tests that might be ordered in a particular circumstance. An anemia workup might be hard to tease apart in a short amount of time. And in oncology testing, I think it’d be hard for an oncologist to go through all their lab orders with a patient to explain how they might impact treatment. They become very complicated and sometimes I think even the oncologist isn’t sure if or how some of these complex tests will be useful.