Millions squandered in unnecessary medical tests
25 May 2006
Washington, DC. A study of preventive health screening
measures such as ECGs, X-rays and laboratory tests has shown that
unnecessary tests are costing the U.S. health care system millions — and
potentially billions— of dollars per year according to researchers from
Georgetown University Medical Center and Johns Hopkins University in the
June issue of the American Journal of Preventive Medicine.
Not only are
the tests unwarranted, but false-positive results lead to further tests and
compound the expense, says the study’s lead author, Dan Merenstein, MD, an
assistant professor in the Department of Family Medicine at Georgetown.
“Many physicians, as well as their patients, appear to believe that a
routine health exam should include a number of tests they feel can screen
for unknown diseases, but the evidence shows that some of these tests are
less than beneficial when used in this way,” he said. “More is not always
better, and understanding this is especially important now that Medicare has
begun to reimburse complete physicals.”
The study looked at
recommendations of the United States Preventive Services Task Force
(USPSTF), a panel of experts that grades preventive screening measures based
on evidence of their effectiveness. The researchers focused on “C” and “D”
tests to see how often they were being used in routine patient visits. In
asymptomatic patients, a “C” test are those tests the panel made no
recommendation for use. “D” tests, are those which the panel recommended
against as risks outweigh the benefits.
These “C” and “D” procedures fell
into two categories: “interventions”—this includes an electrocardiogram
(EKG) that records heart activity and X-rays — and procedures that are
analyzed in a laboratory: a urinalysis; a hematocrit which measures volume
of red blood cells in blood; and a complete blood count, or CBC, which
measures red and white blood cells and platelets, in blood.
To conduct the
study, the researchers reviewed data from the National Ambulatory Medical
Care Survey (NAMCS) sponsored by the Centers for Disease Control. They
analyzed 4,617 general examination visits by adults over age 20. The
researchers then looked at how many of the “D” category tests — urinalysis,
EKG, and X-rays— were ordered, and found at least one of the three D
interventions was ordered 43-46% of the time.
The researchers then
extrapolated their findings into a national picture of use, and estimated
that annual direct medical costs for the three “D” category tests — those
whose use the panel recommended against — ranged from $47 million to $194
million. Adding the other two tests, those in the “C’’ category — urinalysis
and blood tests —added an additional $12-$63 million.
What the numbers
miss, however, according to researchers, are the various costs that occur
when a test is false positive, that is, wrongly shows evidence of a health
problem. For example, studies show that 20-30% of EKG tests result in false
positive results, and patients with these results usually have follow-up
exams that are much more expensive, Merenstein says.
“We estimate that if
20% of EKGs are false, the follow-up tests will cost about $683 million, and
that doesn’t account for the stress that a patient feels, the time off from
work they have to take, and the possible complications that result from the
Among their other findings is that men are given more of
these tests than are women, and that Hispanics are also offered more tests
than non-Hispanic patients.
Merenstein and his two co-authors say among
the many reasons that diagnostic interventions which lack evidence of
benefit in asymptomatic patients are used are:
- studies have shown that many patients have expectations of receiving
particular tests when visiting physicians.
- it is possible that physicians are ordering these tests defensively,
to guard against potential lawsuits.
- physicians may not be aware of USPSTF recommendations.
- there may be a financial incentive to ordering these tests,
especially if a physician’s office includes a laboratory.
“But the fact is that less use of unwarranted interventions will
likely eliminate waste and improve overall quality of healthcare in the
United States,” Merenstein said.
The study was funded by the Robert
Wood Johnson Clinical Scholars Program. Merenstein’s co-authors include Neil
Powe, M.D., and Gail Daumit, M.D., of Johns Hopkins University.