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TELLING medical practitioners what medical tests cost would be a “good start” in ensuring only the most appropriate tests are ordered, according to AMA president Dr Steve Hambleton.
“We are not going to be able to afford everything for everyone, so every person in the health care system … needs to take responsibility every time we order a test”, Dr Hambleton told MJA InSight.
Dr Hambleton was commenting on a US trial published in JAMA Internal Medicine which found that providing fee data at the time of test ordering resulted in a “modest” reduction in tests ordered. (1)
In the 12-month randomised controlled trial, conducted in the Johns Hopkins Hospital, 31 tests were assigned to the control arm and 30 to the active arm where fee data were provided. In the active arm, test ordering per patient day declined by 8.6% when compared with the baseline period, while test ordering increased by 5.6% in the control arm.
Dr Hambleton said while doctors always thought about the benefit to the patient before making a referral, it was also important to consider the cost to the health system.
“We now put the price of all prescriptions on the form printed by the pharmacist, so the patient [on a concessional benefit] knows that the drug they are taking costs $3000 a month and they paid $5.90”, he said.
Dr Hambleton said that even with the complexities of Australia’s “episodic cone” claiming system, which distorted the ultimate cost of tests, a straight price indication would be a “good start”.
Professor Janet Hiller, associate dean of health sciences (research) at Australian Catholic University, said there was certainly scope to address the growth in test ordering in Australia, but many public hospitals already had programs to rein in unnecessary spending.
“Public hospitals are on fixed budgets, they really struggle. I think you will find there are all sorts of small projects happening around [test ordering].”
Professor Hiller said it was more difficult to address the growth in test ordering in general practice.
“How do you stop GPs from ordering panels of tests? They don’t feel the burden and each individual test doesn’t cost very much — it’s the volume.”
Professor Hiller said there were also “fashions” in test ordering. “We know that testing for vitamin D deficiency has grown enormously [and] B12 testing has also grown,” she said.
A systematic review of the validity and reliability of B12 testing, which Professor Hiller coauthored, found that many GPs were unaware of the limitations of the test. (2)
“The GPs we presented the data to were really quite surprised; they had thought it was a better test”, Professor Hiller told MJA InSight.
NPS MedicineWise clinical adviser, Dr Andrew Boyden, said the organisation had been working to improve the quality use of medical tests since 2009.
Dr Boyden said no factor — including visibility of cost — could work in isolation to ensure tests were ordered more judiciously.
“Encouraging the development and promotion of relevant guidelines — and ensuring health professionals have clarity around these guidelines — is crucial, as is having an informed and test-aware consumer base”, Dr Boyden told MJA InSight.
“It’s important health professionals are informed about the strengths and weaknesses of various tests, so they can direct testing towards those who have the most to benefit while minimising the downside of testing”, he said.
Next month, NPS MedicineWise will launch a program to encourage health professionals to make use of evidence-based testing for preventive health in well Australians aged 40–49 years, while avoiding inappropriate testing.
– Nicole MacKee
1. JAMA Int Med 2013; Online 15 April
2. Pathology 2011; 43: 472-481
Posted 22 April 2013
So many comments about the ordering habits of junior docs in hospitals, but who teaches them to do this? It is their own seniors, who ask “did you get the serum rhubarb” , which soon teaches them to get “all the tests”” so as not to get aught out. Rational test ordering in EDs is often thwarted by an admitting team not wanting to take a patient until “all the tests are done.” Junior doctors learn by example.
Should lipid testing be restricted to patients who have seen a Dietician and who have been dietary treatment for 12 weeks prior to testing?
Our system has made access to universal health care an issue of equity. We need to send signals to the community that access relates to clinical need not a right to have every test “just in case”. We as the requesters need the ammunition and the support from government to educate the community but it won’t happen unless there is a political maturity not yet evident in any of the political parties.
I think three ideas have made greatest difference to me as an Emergency doctor when ordering tests.
First “Can I see that the test will make a difference to treatment options and decisions?”
Second “By ordering this test now, which I can imagine is likely to be needed soon down the track, can I save other unnecessary tests, and save a hospital bed for a day?” ie if I order an ultrasound now, which is easy to organise, for someone almost sure to need a CT, do I go straight to the CT (and do I know a comparative cost, and do I know a comparative risk profile, eg from exposure to radiation?)
The third I take straight from Prof Christine Bennett, from the hospital reform process. “Waste is an ethical issue” i.e., If I do this, our system will not be able to respond to greater need elsewhere. This has had an impact on me and also on the people I teach, who sometimes become irritated by my interest in the cost of what we are doing. It helps if the economic reasoning has a political and social context.
Earlier posts decry the decline in clinical skills.
It takes time to do a good history, clinical examination and then to “turn your mind to” the diagnosis. The way the system is, in both Hospitals and community practice (particularly General Practice), is a disincentive to spend that time. And that is not to mention the “just in case” ordering of pathology so that, if necesssary, a defence can be mounted. “Watchful waiting” and review doesn’t easily satisfy when things progress.
I can, as an older GP, do many things for my patients but they require my clinical skills and my time and both have a financial cost: and few wish to pay that cost.
It has often been stated that the most expensive piece of equipment in any public hospital is a pen in the hand of a junior doctor. I am responsible for triaging GP referrals to a gynaecology outpatient clinic in a teaching hospital. The referrals usually contain expensive imaging results as well as a battery of (often unnecessary) pathology tests. Rarely have the patients had a comprehensive history and mostly they have never had an appropriate physical examination. In many instances the imaging reports are inadequate, inappropriate or at worst misleading. The referrals are thus (not surprisingly) often inappropriate. I strongly support the concept of GP’s having the ability to order any appropriate investigations. However it does bother me that so many expensive tests are being done as a substitute for good clinical practice.
Feedback on cost is just one of the strategies needed to improve the quality of pathology use. Junior medical staff need to be taught the proper place of pathology during their first years on the wards: it is here that habits form. Australian graduates used to be admired world-wide for their excellent clinical decision-making skills, thanks to the rigor of our medical schools and Specialist Colleges. Now we have gone the way of the Americans: order a battery of tests first then think about the diagnostic possibilities. Prof Hiller is quite right in pointing out the squeeze this puts on public hospitals in particular, subject to the conflicting effects of unfettered test ordering by junior medical staff and capped episode-based funding budgets. More than ever, we need junior medical staff to be shown proper leadership by clinical pathologists. But where are they? Over the last two decades both public and private pathology operators have pared away the numbers of clinical pathologists, considered a luxury by both. Now we are paying for these ill-informed cutbacks. It is time for pathologists to reclaim their place on the Bridge, to guide their colleagues precisely to the diagnosis and help them to monitor the effects of their interventions.
Enormous sums are wasted on pap testing and over-treatment.
If you compare our program to The Netherlands and Finland you see the harmful excess in our program, it wastes scarce health resources and it harms and worries lots of women. I think the Govt needs to get some urgent and independent advice on women’s cancer screening. Hopefully, the long overdue current review will do what’s best for women. I’m not confident though…excess has always been the norm in this country and non-evidence based testing.
Since the 1960s the Finns have offered women 6-7 pap tests, 5 yearly from 30 to 60 and they have both the lowest rates of cc in the world and they refer far fewer women for colposcopy/biopsies/over-treatment. (that can damage the cervix and lead to premature babies, c-sections, miscarriages etc) Women here are still being urged to have 26 or even more pap tests, 2 yearly from 18 (some start
earlier) to 70, awful over-screening that provides no additional benefit to women, just sends risk, false positives and over-treatment way up. It’s also, unfair to women, many of whom find this test difficult/painful etc….feelings that are often dismissed by the medical profession.
I have watched evidence based programs for many years and feel the Dutch are the ones to watch here. I have never taken part in the Australian program and thankfully, more women are working out this program is not in our interests. The Dutch had the same program as the Finns, but will continue to put women first and move with the evidence, they’ll introduce 5 hrHPV primary triage tests or women can self-test using the Delphi Screener, at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ and at risk will be offered a 5 yearly pap test. This will save more lives and finally spare most women from a lifetime of unnecessary pap testing and the high risk of over-treatment/excess biopsies. I’m not sure what we’re doing in this country apart from wasting health resources, promoting and protecting harmful excess and I’m sure we miss some of these rare cancers with our inefficient excess.
The complete lack of respect for informed consent in women’s cancer screening should be a scandal….men are not treated in this way. Women do not get complete and balanced information on screening, we get scare campaigns, our GPs get target payments for pap testing (never made known to women) misinformation….the entire emphasis is on the govt-set target and pushing women into this excessive program. It says to me we have major issues in this country with the way women are still viewed by the medical profession and that factors other than what’s best for women are permitted to influence these programs. It has been hard to watch so many women being worried and harmed by this program and the shocking fact is….almost all of this damage was avoidable with screening in ethical and evidence based hands.
I have also, declined breast screening. Prof Michael Baum’s research that recently appeared in the BMJ suggests any benefit is almost certainly wiped out by women who die as a result of lung cancer and heart attacks after radiotherapy and chemo. I recently heard Peter Gotzsche from the Nordic Cochrane Institute speak at the Evidence Live Conference in Oxford and his message was clear, breast screening is harmful and should be stopped. The fall in the death rate is about better treatments, not screening. Screening does not save breasts, as often claimed…and about 50% of screen detected cancers are over-diagnosed. All very concerning, yet this program has happily operated without informed consent for decades with women being urged and pressured to screen with no balanced information. The NCI have produced an excellent and unbiased summary of all of the evidence, it’s at their website. It should be provided to every woman, but that’s unlikely to happen, we protect the program, not women. HPV Today, Edition 24, sets out the new Dutch program and Delphi Bioscience can provide information on HPV self-testing. The device can be ordered online…HPV+ and you have a small chance of benefiting from a 5 yearly pap test, HPV- and you cannot currently benefit from a pap test and a recommendation would be made to re-test in 5 or 10 years time, depending on your age, to guard against a new infection. Those HPV- and no longer sexually active or confidently monogamous might choose to stop all further testing.
This is not good medicine.
No. Because it makes the diagnostic decision making too complicated. The best solution is if I try to do the best by my patient and you try to stop me, so to speak.