Cost facts may reduce test ordering

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