Clinical Test Use Does Not Always Reflect High-Value Care

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During our Quality, Value, and Patient Advocacy lecture, we revisited the common theme of addressing healthcare costs. In retrospect, medical school really doesn’t drown us with knowledge about the costs of routine complete blood counts, chest x-rays, etc. These “routine tests” are a very real contributor to the cost of healthcare, especially when many are not necessary and could potentially be harmful.

The article lists 37 clinical situations in which ordering a test does not reflect high-value care (see footnote for link to article); the following situations (in no particular order) are ones which I distinctly remember encountering first-hand.1

  • Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease
  • Obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults
  • Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure
  • Screening for colorectal cancer in adults older than 75 or in adults with a life expectancy of less than 10 years
  • Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients
    undergoing elective surgery
  • Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features
  • Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia

While the article doesn’t take into account the unique circumstances of each patient, it still surprises me how often we do things “just to get a baseline” for a side effect or complication which is exceptionally rare. And defensive medicine certainly doesn’t help the issue.

1. Qaseem, Amir, et al. “Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care.Annals of Internal Medicine. 156 (2012): 147-149.

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