In the Journals

PCPs do not always follow guidelines when ordering tests

Jack O'Sullivan
Jack W. O'Sullivan

Primary care physicians displayed “marked variation” in how often they ordered tests in compliance with testing guidelines, according to a systematic review and meta-analysis recently published in BMJ Open.

“Health costs are soaring in the U.S.A. and U.K., with the percentage of gross domestic product spent on health care continuing to rise. Health care resources can be wasted by subjecting patients to tests and treatments that they don’t need (overuse) and also by depriving patients of a test or treatment when it is required (underuse). The latter wastes resources through delayed diagnoses and treatments,” Jack W. O’Sullivan, DPhil candidate at the Centre for Evidence-Based Medicine University of Oxford in the United Kingdom, told Healio Family Medicine. “Regardless of health care costs, over and underuse can lead to patient harm.”

With Medicare projected to have a $660 billion deficit by 2023, and 55% of all current U.S. based health care decisions made by primary care physicians, it is important to ascertain the validity of primary care diagnostic testing as a sustainability measure for health care systems, researchers added.

O’Sullivan and colleagues extracted 62 measures of inappropriate overuse and 41 measures for inappropriate underuse of 47 diagnostic tests from 63 studies containing 357,171 patients from 15 countries. Studies were excluded if: 20% or more of their participants were younger than 18 years old; the diagnostic tests were not ordered by general practitioners; they did not give an appropriateness level or if appropriateness was measured by comparison to guidelines expressly created for a region or hospital; or they were conducted before 1999.

Researchers found that the overall rate of inappropriate diagnostic test ordering varied substantially (0.2% to 100%), with 17 tests underused more than half the time. Of the tests studied, echocardiography was often underused (between 54% and 89%,); and there were large discrepancies in the rate of inappropriate underuse of pulmonary function tests (between 38% and 78%). Conversely, 11 tests were inappropriately overused more than half the time. Echocardiography was “consistently overused” between 77% to 92% of time, urinary cultures were “inappropriately overused” in between 36% and 77% of cases, upper endoscopy between 10% and 54% of the time and colonoscopy between 8% and 52% of the time.

“The most surprising result was that echocardiograms are consistently under- and overused in primary care,” O’Sullivan said in the interview. “This is concerning because it may indicate that primary care physicians are uncertain when the appropriate time to order an echocardiogram is. Echocardiograms are costly and thus mitigating this uncertainty is important.”

“Guidelines are population-level recommendations, which don’t uniformly fit all patients,” he added. “There will always be times when it is appropriate for a test to be ordered, not in line with a guideline recommendation. However, when doctors do decide to deviate from guidelines, it is important to discuss why they recommend this and that their advice is not in line with recommendations.”

O’Sullivan also said that some guideline recommendations, by their very nature, are not always robust and may not be predicated on the best quality evidence. Future studies, he concluded, should determine which guidelines are indeed robust, trustworthy and make recommendations that are in the patient’s best interest. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

Jack O'Sullivan
Jack W. O'Sullivan

Primary care physicians displayed “marked variation” in how often they ordered tests in compliance with testing guidelines, according to a systematic review and meta-analysis recently published in BMJ Open.

“Health costs are soaring in the U.S.A. and U.K., with the percentage of gross domestic product spent on health care continuing to rise. Health care resources can be wasted by subjecting patients to tests and treatments that they don’t need (overuse) and also by depriving patients of a test or treatment when it is required (underuse). The latter wastes resources through delayed diagnoses and treatments,” Jack W. O’Sullivan, DPhil candidate at the Centre for Evidence-Based Medicine University of Oxford in the United Kingdom, told Healio Family Medicine. “Regardless of health care costs, over and underuse can lead to patient harm.”

With Medicare projected to have a $660 billion deficit by 2023, and 55% of all current U.S. based health care decisions made by primary care physicians, it is important to ascertain the validity of primary care diagnostic testing as a sustainability measure for health care systems, researchers added.

O’Sullivan and colleagues extracted 62 measures of inappropriate overuse and 41 measures for inappropriate underuse of 47 diagnostic tests from 63 studies containing 357,171 patients from 15 countries. Studies were excluded if: 20% or more of their participants were younger than 18 years old; the diagnostic tests were not ordered by general practitioners; they did not give an appropriateness level or if appropriateness was measured by comparison to guidelines expressly created for a region or hospital; or they were conducted before 1999.

Researchers found that the overall rate of inappropriate diagnostic test ordering varied substantially (0.2% to 100%), with 17 tests underused more than half the time. Of the tests studied, echocardiography was often underused (between 54% and 89%,); and there were large discrepancies in the rate of inappropriate underuse of pulmonary function tests (between 38% and 78%). Conversely, 11 tests were inappropriately overused more than half the time. Echocardiography was “consistently overused” between 77% to 92% of time, urinary cultures were “inappropriately overused” in between 36% and 77% of cases, upper endoscopy between 10% and 54% of the time and colonoscopy between 8% and 52% of the time.

“The most surprising result was that echocardiograms are consistently under- and overused in primary care,” O’Sullivan said in the interview. “This is concerning because it may indicate that primary care physicians are uncertain when the appropriate time to order an echocardiogram is. Echocardiograms are costly and thus mitigating this uncertainty is important.”

“Guidelines are population-level recommendations, which don’t uniformly fit all patients,” he added. “There will always be times when it is appropriate for a test to be ordered, not in line with a guideline recommendation. However, when doctors do decide to deviate from guidelines, it is important to discuss why they recommend this and that their advice is not in line with recommendations.”

O’Sullivan also said that some guideline recommendations, by their very nature, are not always robust and may not be predicated on the best quality evidence. Future studies, he concluded, should determine which guidelines are indeed robust, trustworthy and make recommendations that are in the patient’s best interest. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.