Observation Deck: The Doctor’s Dilemma

By Mark Thill

What contracting executive would pass up a chance to have a productive, non-combative heart-to-heart with the medical staff on ways to reduce the cost and utilization of medical supplies and equipment? Right. None.

In the past, that conversation may have been one-sided, but that may be changing. Witness the American Board of Internal Medicine’s “Choosing Wisely’ initiative, on which we reported in last month’s digital issue, and which we revisit this month. Briefly, medical specialty societies have stepped up to identify tests and procedures that fail to provide as much value as they should. If their members adhere to these recommendations, the result could be reduced utilization, reduced cost, and better patient care.

But getting from here to there won’t be easy, as a recent editorial by Brian F. Mandell, MD, PhD, editor-in-chief of the Cleveland Clinic Journal of Medicine demonstrates.

The Cleveland Clinic Journal and the American College of Physicians have collaborated to create a series called “Smart Testing,” which will present clinical scenarios in which diagnostic tests are commonly ordered in the absence of supporting data. The first one? A healthy, 48-year-old insurance executive is offered the option of several health insurance packages at the time of a promotion. Should he get a stress test to best guide his care?

The Institute of Medicine estimates that $765 billion is wasted annually in the United States on care that provides no value to patients, said Dr. David Fleming, president of the American College of Physicians, in a statement accompanying the July scenario. “‘Smart Testing’ clinical vignettes and discussions illustrate the appropriate use of imaging tests and other diagnostic procedures, of which overuse and misuse account for an estimated $210 billion of our wasted healthcare dollars.”

“Smart Testing” is part of ACP’s High Value Care initiative, which is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues, so together, they can pursue care that improves health, avoids harms, and eliminates wasteful practices.

“Value is not merely cost,” the ACP said in a statement. “Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests or treatments have low value because they do not provide enough benefit to justify even their low costs, and might even be harmful.”

In his editorial, Mandell points to the dilemma facing doctors at the point of care.

“We like to think we practice evidence-based diagnostic testing,” he writes. “We talk about the gold-standard value of randomized controlled trials and using published data on pre-test and post-test diagnostic likelihoods to assist us in choosing the appropriate test. However, the individual patient in front of us may have comorbidities that would have excluded her from the randomized trials. Who knows if my diagnostic acumen in determining the pre-test likelihood of disease is better or worse than that of the clinicians who published the paper on the utility of that test? Sometimes choosing a test is not so simple.

“Much of my clinical decision-making occurs in a gray zone of uncertainty. Rarely will a single test provide an indisputable diagnosis. So, I may bristle when someone, often for cost reasons, questions the necessity of a diagnostic test that I have ordered to help me understand a clinical problem in a specific patient.”

“I do not minimize the financial impact of inappropriate testing, but in the clinic I am a doctor, not a businessman,” Mandell continues. “I am far more swayed by clinical arguments than financial ones when making decisions for the patient on the examining table in front of me.

“Despite the general examples I provided above as to why regulated, cookbook approaches to test-ordering may lead to suboptimal care and physician and patient dissatisfaction (albeit while decreasing costs), sometimes ordering certain tests in certain circumstances just doesn’t make sense. Yet, there are many questionable test and scenario pairings that are ingrained in common practice. Some we learned during our training but have become less useful in light of new knowledge, some we may have adopted because of anecdotal experiences, and some are ‘demanded’ by our patients. It is these that we hope to help expunge from routine clinical care.”

The answer
And that 48-year-old insurance executive?

“On the basis of current data, the insurance executive should not get a stress test because the results of the test are unlikely to have an impact on his medical management, are unlikely to improve his clinical outcome, and carry a small risk of harm,” write the “Smart Testing” authors, citing guidelines from the US. Preventive Services Task Force and American Academy of Family Physicians. “Low-risk, asymptomatic people with a positive stress test have the same mortality rate as those who have a negative stress test, and its usefulness beyond traditional risk-factor assessment in motivating patients and guiding therapy has not been established. In addition, the rate of false-positive results with exercise stress testing is as high as 71 percent.

“Although the risk of an adverse event from the initial stress test is low, i.e., one serious event in 10,000 tests, the risk of subsequent cardiac catheterization after a positive test is significantly higher, i.e., 170 serious events in 10,000 tests.

“For these reasons, the potential harm of exercise electrocardiography outweighs the benefits in this patient.”