More Than Money and Lawsuits Drive Overtesting: Study

Managed Care

Last Updated: 2013-06-11 19:30:24 -0400 (Reuters Health)

By Andrew M. Seaman

NEW YORK (Reuters Health) - Despite reports that financial incentives and fear of lawsuits lead to overordering of cardiac studies, data from a U.S. Veterans Affairs (VA) study suggests overtesting may arise from more fundamental issues.

Researchers at one Florida VA facility found its doctors, who don't get paid for the tests they order and are rarely sued, order as many unnecessary nuclear stress tests as doctors at traditional hospitals.

"At least looking at it from our facility, the rate or practice of overuse is not different that what's been previously described," said lead author Dr. David Winchester, from the Malcom Randall VA Medical Center in Gainesville.

Nuclear medicine stress tests can cost up to $1,000. A group of medical societies, including the American College of Cardiology Foundation and the American Heart Association, set guidelines on when patients should get nuclear stress tests, but the researchers wrote Monday in JAMA Internal Medicine that as many as a quarter of tests are still considered unnecessary.

Someone with chest pain is an appropriate patient for a nuclear stress test, Dr. Winchester told Reuters Health. An inappropriate patient, on the other hand, has risk factors for heart disease but no symptoms.

The researchers thought the number of inappropriate stress tests ordered at their facility would be lower than previously reported, because VA doctors aren't usually influenced by financial gain or fear of being sued.

Between December 2010 and April 2011, there were 332 nuclear stress test performed at their medical center.

According to the guidelines set by the medical societies, 78% of the tests were appropriate, 13% were inappropriate, and the rest fell into an "uncertain" category.

An accompanying note from Dr. Deborah Grady, an editor at JAMA Internal Medicine, says it could be that "the culture of overordering is ingrained" into doctors.

"I think culture trumps everything else. Culture even trumps evidence," said Dr. Patrick O'Malley, an internist at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, who didn't participate in the new study.

"It's clearly an area that warrants further investigation to see what's going on in the patient-physician relationship and what's driving physicians to order tests that's otherwise considered to be inappropriate," Dr. Winchester said.

SOURCE: http://bit.ly/1bsoJ2X

JAMA Intern Med 2013.

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