Wasteful Diagnostic Testing Situations Listed by ACP — Physician’s First Watch

Medical News |
January 17, 2012

Wasteful Diagnostic Testing Situations Listed by ACP

An ad hoc group of internists convened by the American College of Physicians has identified a series of clinical situations that frequently lead to wasteful diagnostic tests.

By consensus, the group identified some 40 situations, which include the following:

  • Assessing brain natriuretic peptide in the initial evaluation of typical heart failure findings

  • Ordering imaging studies for nonspecific low back pain

  • Utilizing MRI instead of mammography to screen for breast cancer in women at average risk

  • Conducting serologic testing for suspected early Lyme disease

The Annals of Internal Medicine's editor invites readers to comment on or add to the list by taking a survey on the journal's website. She remarks that "unnecessary testing abounds," and cites a Congressional Budget Office estimate that "up to 5% of the nation's gross national product is spent on tests and procedures that do not improve patient outcomes."

Reader Comments (5)

Mary E Simons

When false positives are common, diagnostic testing may be called wasteful or worse since false positives may lead to additional testing or therapy that does the patient more harm than good.

Senior lymphoma clinicians have reported said that relapse of NHL is "inevitable" for patients in remission but that an annual PET scan--to detect remission before symptoms become obvious--is not advised because there are too many false positives.

A contrary view is that such a "No PETS Allowed" policy is like saying a hurricane is inevitable but don't watch weather reports because there are too many false warnings.

Although not doing a test is one way to avoid false positives from that test, a safer way could be raising the threshold for response so that no further tests and no therapy is done unless the extent of positive is not just marginal but extreme.

Competing interests: None declared

Ronald N. Levy

When a frightened patient in the exam room says "please save me," he is not asking the doctor to save him money by not doing a diagnostic test.

The cost of doing tests is measurable in dollars but the cost of not doing enough tests may be measurable in lives.

"Less is more" is a motto of some futuristic architects and minimalist artists but is not a chant of universities seeking knowledge nor of doctors seeking enough information to help them make life-saving decisions.

The case for diagnostic medical tests is that it is often better to know more than to know less. Thrift is important but what's best for thrift may not be the same as what's best for the patient.

False positives can be annoying but false economy can be fatal.

Look at two ways, one of them more obvious, to cope with false positives that may lead to more tests and therapy that do the patient more harm than good:

1. Don't do the test and reason that it's better not to know than to fall for a test result that is a false positive.

2. Do the test but don't react to a positive--no more tests and no therapy--unless results are not just positive but alarmingly positive.

A little knowledge can be a dangerous thing but not enough knowledge can be fatal.

Competing interests: None declared

Chris Lupold

How timely of an article. I was reading this just prior to going in to see a 69 yo male patient new to our office here for a physical. He was confused why I didn't want an EKG, UA and stool cards done every year (his colonosocpy is UTD and he has no symptoms, his previous EKGs have been normal and he has not symptoms, etc). He wanted follow-up blood testing done for Lyme disease (again asymptomatic). You can begin to imagine the discussion we had about PSA testing. Very difficult but pleasant visit. Waiting to see what my patient satisfaction survey looks like with this patient. I provided quality cost effective care to him but did I succeed in convincing him of this. Time will tell.

Competing interests: None declared

James A Benson

So many things - but here should be an easy one: Coag screen for every patient who comes to ED; if they aren't going to get thrombolytics (such as when they have anormal EKG & troponin), this test adds nothing but it is done all the time.

Also, is not lipid management done in the outpatient setting? Doesn't an acute illness affect your lipids? Why do we do them during a hospitalization?

Competing interests: None declared

S C Hawthorne

I do agree with this article; however, as primary care physicians it is sometimes quite challanging for us to convince our patients that some of these tests are not needed. At times the patientes trust their next door neighbor or some TV show more then us. And at times we don't have the time to fight this uphill battle. I had in one instance a lady who demanded that the get a MRI of her breasts even though she had a mammo a few months past for she was convinced her symptoms were secondary to breast cancer even though both myself and a colleague of mine explained to her very throughly that her symptoms were secondary to cervical radiculopathy. Also as primary care physicians we get a whole lot more scrutinization then the er physicians. From what I see they can order whatever they like without much questioning and with much less evidence to support their rationale.

Competing interests: None declared

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