Why do docs overorder tests?

There’s an awesome study that was just published in JAMA Internal Medicine, “Appropriate Use of Myocardial Perfusion Imaging in a Veteran Population: Profit Motives and Professional Liability Concerns“:

Myocardial perfusion imaging (MPI) is performed millions of times annually in the United States to assess patients for coronary ischemia. Some have expressed concern that MPI is being used inappropriately, possibly because of self-referral profit motives and professional liability fears. To inform clinicians about situations in which patients are likely to benefit from MPI testing, appropriate use criteria (AUCs) for MPI were developed, last revised in 2009. Prior investigations have applied AUCs to describe the magnitude and patterns of inappropriate testing. Rates of inappropriate testing have ranged from 7% to 24%. We hypothesized that the single-payer environment of the Veterans Affairs (VA) health system, which eliminates self-referral profit motive and limits liability concern, will result in less inappropriate use of MPI.

Anyone who visits this blog regularly knows that one of my foci of interest in the fact that doctors do too much. Many of you believe that’s because they fear being sued, and they are practicing defensive medicine. I’ve often argued that I think the profit motive can’t be ignored – the more docs do, the more they generally get paid.

The genius of this study is that it was conducted in the VA setting. Because it’s the VA, and the docs are salaried government employees, there no profit motive involved. If they do more, they don’t get paid more. Moreover, because they work for the federal government, malpractice is handled differently. Almost all cases are handled administratively. In fact, only three judgments were recorded against the US for malpractice tort cases in 2010. Therefore, there is really no impetus to practice defensive medicine. Logic would tell us, therefore, that there is no reason to order unnecessary tests.

This study chose to look at myocardial perfusion imaging, which is often used inappropriately. In a four and a half month time period, they identified 332 patients who got the study in the VA system. Only 78% were clearly appropriate. 13% were inappropriate, and 8% were uncertain.

Why are docs doing this? My guess is that it’s just incredibly hard to change physician behavior. But what’s clear is that it’s not simply greed, and it’s not simply fear. Ironically, those things are easier to fix. We’ve got our work cut out for us.


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