BETWEEN 2000 and 2008, the number of Medicare funded pathology tests increased 54% in Australia, a volume increase from 62.1 million to 95.7 million tests. Over this period, pathology costs increased from $1.2 billion to $1.9 billion.
However, 25–75% of tests are not supported by evidence. Inappropriate testing increases health care costs, wastes resources and incurs further costly delineation of incidentalomas that may also bring on harmful treatment. Excessive reliance on testing has been allowed to supplant clinical acumen. It is crucial that GPs identify patient concerns and address expectations on the rationale for individual test ordering.
Although GPs experience pressure to comply with parent or patient requests for diagnostic tests to preserve good relations and avert medicolegal liability stemming from missed or delayed diagnosis, there are risks and harms associated with ordering tests that are not clinically appropriate.
Tests can be painful and anxiety-provoking, and lead to unnecessary, expensive and potentially dangerous further work-up and treatment. Denying test requests requires GPs to explain their reasoning to patients in a sensitive and assertive manner.
It’s in the GPs’ interest to not annoy or alienate patients by recommending only necessary radiology and pathology tests. So why are GPs subjecting patients to the personal inconvenience and out-of-pocket cost of expensive tests that are not recommended?
Surely patients’ unrealistic demands contribute to spiralling health care costs, as unnecessary pathology and radiology testing in outpatient practice are being driven by the need to satisfy patient expectations. Anxious patients and parents whose requests for non-rational testing are declined are going to vote with their feet and decamp to the surgery down the road. This negatively impacts on the caseload for the GP that dares to slow down uncontrolled cost.
Most of us realise that the bulk of general practice presentations are self-limiting illnesses that require not much more than rest, symptom relief and reassurance, without the need for any blood tests or x-rays.
Although better education regarding, and adherence of GPs to, clinical guidelines will help contain burgeoning use of expensive diagnostic testing, the community needs to do its bit by quelling its demand for unnecessary tests to discern the rare “just in case it is something serious” eventuality. Public education campaigns to promote sensible health behaviour and reasonable expectations targeting unnecessary high volume or expensive diagnostic testing may help curtail patient-generated demand. A notable example is yearly routine blood tests for annual health check-ups in healthy older patients. I frequently encounter instances of bed-bound patients in nursing homes who have their lipid and vitamin D levels done. These then lead to interventions addressing high cholesterol level and lack of sun exposure that are not going to improve the quality of life in any meaningful way.
Medicare could also reward GPs for taking the much-needed time to explain to overconcerned patients why further testing is not indicated, costly and sometimes even harmful.
The overuse of diagnostic tests is being driven by the GP community’s need to keep their patients satisfied and eager to return to the same practice. This attitude, however, incurs unnecessary health care costs that will become untenable.
Following up incidental findings from non-clinically appropriate tests incurs further potentially invasive, risk-prone and harmful testing. Such abnormalities in isolation were never related to a patient’s complaint, and would feasibly not have caused symptoms during a patient’s lifetime.
Recent examples include prostate biopsies for high prostate-specific antigen (PSA) levels detected in older men with no lower urinary tract obstructive symptoms. The PSAs were ordered by GPs as a screening test in a low risk group and incurred frequent false positives that necessitated anxiety-provoking biopsies.
Deep biopsies of benign lesions detected on brain computed tomography and magnetic resonance imaging (MRI) scans cause fear and anxiety at the procedure and the several days of delay to histopathology reporting.
Spinal MRIs for adults with low risk chronic low back pain often show minor degenerative changes that do not correlate with the degree of disability and pain, with a substantial proportion of such patients then inappropriately referred to neurosurgeons for surgery.
Tests are not only expensive but, when unnecessary, require further diagnostic delineation and sorting out with specialists.
GPs could be taught to be more thoughtful about diagnostic testing, which would ideally involve formal Royal Australian College of General Practitioners training about performance characteristics of a test and clinical indications for testing.
Importantly, strategies such as reassurance, watchful waiting and de-escalating unreasonable patient demands require Medicare remuneration, as they take up a lot of consultation time. It’s worth considering that Medicare could pay GPs a bonus for only ordering tests that are clinically indicated.
Joseph Ting is an adjunct associate professor in the School of Public Health and Social Work at Queensland University of Technology in Brisbane.
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