• What can Dartmouth do?

    Last week, members of the American College of Physicians published an Annals of Internal Medicine paper with the abstract:

    Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests—meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.

    The workgroup came up with 37 tests not reflective of high-value, cost-conscious care. They appear below. My question, probably of Dartmouth researchers,* is, would available Medicare (or other) data support an investigation of costs and geographic variation associated with these 37 tests? Naturally, many questions would have to be answered about how to allocate downstream costs if testing led to additional care. So, my question isn’t precisely how to do it, it’s whether it’s reasonable to even think it’s possible.

    If so, it would be nice to see them ranked by cost and variation or jointly by some combination of the two. Cost indicates how big a fiscal drag they impose (how much waste). Variation suggests how much change might be possible within the current range of our health system. E.g., if there is very little variation, it would seem harder to get providers to change. There would be few places to point to that do better. If variation is considerable, there would seem to be more hope.

    My ambition wouldn’t be to get things exactly right, but to at least give some reasonable priority ranking according to cost and variation. So long as things weren’t biased, the relative values would be informative of priority.

    Of course other criteria matter too, like harms to health. But those are more difficult to assess in a uniform, quantitative, and systematic way. Costs and utilization variation are good places to start. Note that one could ask the same questions of any prioritized list of health interventions or health system arrangements with questionable or uncertain value, such as that produced by the IOM or forthcoming by PCORI.

    1. Repeating screening ultrasonography for abdominal aortic aneurysm following a negative study

    2. Performing coronary angiography in patients with chronic stable angina with well-controlled symptoms on medical therapy or who lack specific high-risk criteria on exercise testing

    3. Performing echocardiography in asymptomatic patients with innocent-sounding heart murmurs, most typically grade I–II/VI short systolic, midpeaking murmurs that are audible along the left sternal border

    4. Performing routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3–5 y

    5. Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function

    6. Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease

    7. Obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults

    8. Performing an imaging stress test (echocardiographic or nuclear) as the initial diagnostic test in patients with known or suspected coronary artery disease who are able to exercise and have no resting electrocardiographic abnormalities that may interfere with interpretation of test results

    9. Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure

    10. Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles

    11. Using MRI rather than mammography as the breast cancer screening test of choice for average-risk women

    12. In asymptomatic women with previously treated breast cancer, performing follow-up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging

    13. Performing dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 y in the absence of risk factors

    14. Screening low-risk individuals for hepatitis B virus infection

    15. Screening for cervical cancer in low-risk women aged 65 y or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease

    16. Screening for colorectal cancer in adults older than 75 y or in adults with a life expectancy of less than 10 y

    17. Repeating colonoscopy within 5 y of an index colonoscopy in asymptomatic patients found to have low-risk adenomas

    18. Screening for prostate cancer in men older than 75 y or with a life expectancy of less than 10 y

    19. Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk

    20. Performing imaging studies in patients with nonspecific low back pain

    21. Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology

    22. Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery

    23. Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding

    24. Performing serologic testing for suspected early Lyme disease

    25. Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease

    26. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes

    27. Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination

    28. Performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination

    29. Routinely performing echocardiography in the evaluation of syncope, unless the history, physical examination, and electrocardiogram do not provide a diagnosis or underlying heart disease is suspected

    30. Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery

    31. Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features

    32. Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism

    33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism

    34. Performing follow-up imaging studies for incidentally discovered pulmonary nodules 4mm in low-risk individuals

    35. Monitoring patients with asthma or chronic obstructive pulmonary disease by using full pulmonary function testing that includes lung volumes and diffusing capacity, rather than spirometry alone (or peak expiratory flow rate monitoring in asthma)

    36. Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia

    37. Screening for chronic obstructive pulmonary disease with spirometry in individuals without respiratory symptoms

    * Investigators other than those at Dartmouth could, of course, study the questions I post. I just don’t know who those investigators would be.

    AF

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    • Just within my network there is a lot of variation in pre-op testing and echocardiography. It is an area of interest for most hospitals. However, at this point, most hospitals still get paid for many of these not needed tests. Hospitals that carry their own insurance are more interested. I suspect that a study looking at hospitals which offer their own insurance product vs those that do not might be fruitful.

      Steve