How doctors are sparing patients from heart tests they don't need

​Doctors ordered fewer unnecessary heart tests after they watched an educational video and received monthly feedback reports, according to a new randomized study in Ontario and the U.S.

Telling clinicians how they're doing called a powerful tool in reducing unnecessary echocardiograms

Doctors ordered fewer unnecessary heart tests after they watched an educational video and received monthly feedback reports, according to a new randomized study in Ontario and the U.S.

Echocardiograms are ultrasounds of the heart and one of the most common diagnostic tests, cardiologists say. Clinicians order the non-invasive tests unnecessarily at times, leading to false positive findings that can snowball into more invasive tests and potentially harm patients.

It's one example groups such as the Canadian Institute for Health Information and Choosing Wisely Canada have focused on reducing the more than one million unnecessary medical tests and treatments ordered each year across the country that don't contribute to patient care. 

Echocardiograms allow physicians to visualize heart function, such as watch the organ beat, check if a valve is leaking or look for damage after a heart attack. 

Now Dr. Sacha Bhatia, a cardiologist at Women's College Hospital and Toronto's University Hospital Network, and his team have tested a way to reduce unnecessary echocardiograms, at least in the short term. The tests now cost the health-care system in Ontario more than $190 million a year, he said. 

In Monday's issue of the Journal of the American College of Cardiology, Bhatia and his co-authors reported the results of their trial, called Echo Wisely. The researchers randomly assigned 196 physicians in Toronto, Kingston, Ont., and Boston to receive an educational video and individualized monthly feedback from an app or to continue ordering as they were. 

The investigators adapted existing guidelines on ordering tests for the app. Then trained research assistants checked whether tests were considered appropriate based on the guidelines and information from patients' medical charts. To prevent bias in the analysis, the assistants didn't know which group the participating physicians were in . 

Better technology useful to patient?

Cardiologists and primary care providers who received the support had a lower rate of unnecessary testing (8.6 per cent) compared with those who did not (11.1 per cent), Bhatia and his team said.

"Often times, because our technology has gotten better and better … we tend to see things that may or may not be useful to the patient," Bhatia said in an interview.

Bhatia said he didn't realize the extent to which the feedback would make a difference, and it got him thinking about how physicians rarely receive any.

"[Telling] people how they're doing can help drive improvements in performance even when it's not tied to any incentives."

Bhatia called the individual feedback and anonymous findings of doctors' peers a powerful tool to change their behaviour.

While physicians have a history of striving for high grades and are motivated to improve their performance, Bhatia acknowledged that once feedback on their behaviour stops, a U.S. study suggests they revert back to what they were doing previously.

There's been a dramatic increase in health-care spending on services that haven't been shown to improve patient outcomes, which is driving the push to decrease inappropriately ordered tests, Dr. Randolph Martin of Emory University Medical School in Atlanta, Ga., said in a journal editorial published with the study.

Martin said we need "simple and easy" ways to educate those who order tests inappropriately, such as those aimed at the top culprits of routine surveillance.

For instance, Martin said, automated analytical software could incorporate artificial intelligence and machine learning into electronic medical records to notify those who ordered the test whether one has been done recently and to question whether it will improve a patient's care. 

Since the study participants were mainly from teaching hospitals, Bhatia expects the findings would apply elsewhere in Canada.

It's not clear if it would generalize to doctors working at community hospitals or in private offices where many of these tests are done. The long-term sustainability also needs to be studied.

Overall, it's estimated that 30 per cent of testing in Canada may be unnecessary. 

With files from CBC's Amina Zafar