Popular theories suggest that physicians are driven to order excessive tests by fear of lawsuits and financial incentives, but a new study in JAMA Internal Medicine indicates that more fundamental issues are at play.
For the study, researchers at Malcom Randall VA Medical Center in Florida determined whether the 332 nuclear stress tests ordered at their facility between December 2010 and April 2011 were necessary. According to the American College of Cardiology Foundation and the American Heart Association, as many as 25% of nuclear stress tests—which can cost up to $1,000—ordered at U.S. hospitals are superfluous.
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The researchers found that VA physicians—who do not get paid for ordering more tests and are rarely sued—order just as many unnecessary nuclear stress tests as doctors at traditional hospitals. Specifically, researchers found that 78% of the tests ordered at the VA facility were considered appropriate, while 13% were deemed inappropriate and 9% fell into an "uncertain" category.
"At least looking at it from our facility, the rate or practice of overuse is not different that what's been previously described," lead author David Winchester said. Aside from increasing health costs, inappropriate nuclear stress tests can generate false positives that can lead physicians to order unnecessary medical procedures, including stents.
Winchester added that "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 [are] otherwise considered to be inappropriate."
JAMA editor Deborah Grady suggested in an accompanying article that "the culture of over-ordering is ingrained" into physicians.
Similarly, Uniformed Services University of the Health Sciences internist Patrick O'Malley told Reuters that "culture trumps everything else. Culture even trumps evidence."
O'Malley said that ultimately patients must get involved. "Patients can play a role in questioning their doctor about the value of the tests," O'Malley said (Winchester et al., JAMA Internal Medicine, 6/10; Grady, JAMA Internal Medicine, 6/10; Seaman, Reuters, 6/11).