F is for fail: U.S. fails to curb excessive testing

As policymakers and providers struggle to contain healthcare costs and provide capacity, researchers reported Medicare beneficiaries often undergo repeat echocardiography and stress tests as well as chest CT exams, according to a study published online Nov. 19 in Archives of Internal Medicine. The U.S. has failed to curb excessive testing, according to an accompanying editorial.

There is a paucity of research focused on patterns of repeat testing, according to H. Gilbert Welch, MD, MPH, of the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., and colleagues. “Tests that are routinely repeated following a brief period require 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,” wrote Welch and colleagues. Short intervals between tests also raise costs.

Welch and colleagues sought to describe repeat testing in practice, focusing on six tests—echocardiography, imaging stress exams, pulmonary function tests, chest CT, cystoscopies and upper endoscopies. They selected a five percent random sample of Medicare beneficiaries. These 743,478 patients underwent an index test between Jan. 1, 2004, and Dec. 31, 2006, and were followed for three years.

Fifty-five percent of beneficiaries who underwent echocardiography had a second test within three years, a result that suggests some physicians may be routinely repeating diagnostic tests. In fact, some patients may be undergoing annual echocardiography despite the American College of Cardiology Foundation's Appropriate Use Criteria Task Force’s recommendation against routine surveillance echocardiography. 

The situation may be similar for annual imaging stress tests, as 44 percent of beneficiaries had repeat tests within three years, according to Welch et al.

Other exams are not subjected to clear external standards, which leaves decisions about repeat testing up to clinical discretion. Pulmonary function tests, chest CT, cystoscopies and upper endoscopies were repeated within three years at rates ranging from 35 percent to 49 percent. 

Welch and colleagues also reviewed the data for the 50 largest metropolitan statistical areas in the U.S. and found a high positive correlation of the population tested with the proportion of tests repeated. The finding suggests substantial variation in physician testing thresholds across the U.S., according to Welch et al.

“[Repeat] testing is a major risk factor for incidental detection and overdiagnosis,” wrote Welch and colleagues.

Repeat testing can be justifiable, according to invited editorialists Jerome P. Kassirer, MD, from Tufts University School of Medicine in Boston, and Arnold Milstein, MD, MPH, from Stanford University School of Medicine in Stanford, Calif. “Repeat testing out of curiosity, to ratchet up the likelihood of an almost certain diagnosis, to satisfy a patient’s demand, to reduce the risk of an unwarranted malpractice claims, or to increase profitability does not [represent good practice.]”

The editorialists suggested the need for stronger policies and systems to curb overuse. These include expansion of peer-designed active electronic clinical guidance systems and faster retirement of fee-for-service incentives, according to Kassirer and Milstein.