Could spendthrift doctors bankrupt health care?
It's a perennial problem: spiraling health care costs, and funding that falls short. Something we don't hear much about is doctors wasting a lot of money on unnecessary tests. A campaign called Choosing Wisely aims to reverse that, but a study just published in the Canadian Medical Association Journal says doctors haven't got the message.
The Choosing Wisely campaign was started in the US by the American Board of Internal Medicine back in 2012. The Canadian version of Choosing Wisely launched in April 2014. The goal of these campaigns is identify top five lists of unnecessary tests and treatments, to educate doctors, and to encourage them to have conversations with their patients about tests and treatments that are either not supported by clinical evidence or are out and out useless and unnecessary. Another goal is to carry out studies that show Canadians how often doctors order unnecessary tests and how much it costs the system.
The study found that unnecessary testing continues to be quite widespread. Back in 2007, the American Heart Association recommended that doctors not order heart tests like echocardiograms and treadmill testing and chest x-rays on a routine basis on patients undergoing low risk procedures like cataract surgery, colonoscopy, hernia operations and arthroscopic knee surgery. Researchers at the Institute for Clinical Evaluative Sciences in Toronto looked at more than 1.5 million Ontario patients over a five-year period ending in 2013. The patients underwent a total of more than 2.2 million low risk procedures. In a third of the operations, an ECG was done. That's more than 700,000 unnecessary ECGs. As well, nearly a quarter of a million unnecessary chest x-rays were done.
The study found several reasons why such unnecessary testing takes place. Age was an important factor. The older the patient, the more likely the doctor ordered unnecessary preoperative tests. The type of surgery was a factor as well. If the patient was admitted to hospital, they were more likely to have unnecessary testing than if the procedure was done on an outpatient basis. There were tremendous regional differences in the rate of unnecessary testing. What's surprising is that within individual hospitals, there were huge variations in unnecessary tests. At some hospitals, in one department, the unnecessary test rate was practically zero; in others, it was close to 90 per cent of the patients with low risk procedures getting an unnecessary ECG. If the patient had a preoperative consultation with an internist or an anesthesiologist, they were more likely to have unnecessary testing.
I have mixed feelings about the problem. I have had close family members who had unnecessary testing that was painful, anxiety provoking, and cost the system a lot of money. As a doctor in the ER, it takes me five minutes to order a test that I believe to be unnecessary and considerably longer to convince a patient they don't need the test. There's a bias in medicine towards ordering a test because doing so is seen as doing something where not ordering the test is seen as doing nothing.
On a practical level, if I weigh carefully the value of each test one by one while on duty in the ER, I could spend an hour just thinking about one patient when I'm supposed to see four or five patients an hour. I tend to throw a kitchen sink's worth of tests at the patient because that way, I can reach a diagnosis faster than by ordering them one at a time.
The article suggest one way to begin to solve the problem of unnecessary testing. The fact that some hospitals carry out many more unnecessary tests than others gives us a good clue. The Canadian Institutes for Health Information or CIHI puts out comparative statistics on things like hospital infection rates and the chances of dying following surgery. I'd love to see CIHI identify hospitals that order unnecessary tests. I have no doubt that outing the outliers would change their behaviour quite quickly.
Perhaps we should consider financial penalties to hospitals and even to doctor who order unnecessary tests. It's no trivial matter: unnecessary tests cost the system money it can't afford, not to mention needless inconvenience and anxiety. It's time we did something about it.