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More than money and lawsuits drive overtesting: study

By Andrew M. Seaman

NEW YORK (Reuters Health) - Despite reports that financial incentives and fear of lawsuits lead doctors to order too many heart tests, a new study of U.S. Veterans Affairs (VA) doctors suggests overtesting may be the result of 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 Dr. David Winchester, the study's lead author from Malcom Randall VA Medical Center in Gainesville.

Nuclear stress tests use radioactive dye and low-doses of radiation to help doctors see how well blood flows through the heart. The test 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 write in JAMA Internal Medicine that as many as a quarter of tests are still considered unnecessary.

Someone with chest discomfort who may have a blockage in their heart is an appropriate patient for a nuclear stress test, Winchester told Reuters Health. An inappropriate patient, on the other hand, is someone who has risk factors for heart disease but no symptoms of a blockage.

Aside from the costs of the tests, he said inappropriate screening can produce false positives that may lead patients to have unnecessary medical procedures - such as stents.

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.

Compared to the guidelines set by the medical societies, 78 percent of the tests were considered appropriate and 13 percent were deemed inappropriate. The others fell into an "uncertain" category.

Winchester said it could be that the doctors are ordering the inappropriate tests because they think it's the right thing to do, "but they don't realize that the patient is a low enough risk that this is actually unnecessary."

‘OVERORDERING IS INGRAINED'

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," Winchester said.

O'Malley added that patients can help themselves by being involved in the ordering process.

"Patients can play a role in questioning their doctor about the value of the tests," he said, adding that patients should also think about their next step if the test is positive or negative.

SOURCE: http://bit.ly/1bsoJ2X JAMA Internal Medicine, online June 10, 2013.

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