And while you are improving patient outcomes and saving money on unnecessary oxygen therapy and transfusions (see the above February 2012 What’s New in the Patient Safety World colums “More Bad News on Transfusions” and “More Evidence of Harm from Oxygen”), consider also taking the advice of an American College of Physicians consensus (Qaseem 2012) on avoiding certain screening and diagnostic tests that are of low value.
That group put together a list of 37 tests or testing scenarios that they do not consider to be high-value cost-conscious care. Examples:
The group used several principles to frame their questions about the value of testing in various clinical scenarios, including:
· Will the test results likely change management of the patient’s care?
· Is the likelihood of a false positive test higher than that of a false negative test (for low probability pretest conditions) and would false positive results likely lead to further testing or treatment that might be harmful?
· What are the downstream costs that occur after a test?
The editorial accompanying the article (Laine 2012) adds a couple other pertinent questions to ask before ordering tests:
· Did the patient have the test previously? If so, is there really a need to repeat it? Or can I just get the result of the test done elsewhere?
· What is the potential danger over the short term if I do not order the test?
· Am I ordering this test primarily because the patient wants it or to reassure the patient?
We suspect they would have added a 38th practice to avoid had a study published in the New England Journal of Medicine this January (Gourlay 2012) been available. While the ACP group recommended not screening for osteoporosis routinely in women under the age of 65 with no risk factors, they had no recommendations about repeat screening for osteoporosis in women aged 65 and older. The new study analyzed almost 5000 women in the Study of Osteoporotic Fractures (SOF) who were age 67 or older, had normal bone density or osteopenia at entry and no fractures and were followed prospectively for at least 15 years. They were able to estimate that osteoporosis would develop in less than 10% of older postmenapausal women during rescreening intervals of about 15 years for women with normal bone density or mild osteopenia, 5 years for women with moderate osteopenia, and one year for women with advanced osteopenia. It is likely that these will serve as guidelines to help reduce the number of unnecessary repeat bone densitometry testing.
There are many opportunities to reduce health care costs while preserving or improving patient outcomes. Practices like these and the ones noted in the recent article “Principles of Conservative Prescribing” (Schiff 2011) are common sense approaches that are evidence-based that we can all apply to all our patients.
Qaseem A, Alguire P, Dallas P, et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med 2012; 156: 147-149
Laine C. High-Value Testing Begins With a Few Simple Questions. Ann Intern Med 2012; 156: 162-163
Gourlay ML, Fine JP, Preisser JS, et al. for the Study of Osteoporotic Fractures Research Group. Bone-Density Testing Interval and Transition to Osteoporosis in Older Women. N Engl J Med 2012; 366 :225-23
Schiff GD, Galanter WL, Duhig J, et al. Principles of Conservative Prescribing. Arch Intern Med. Published online June 13, 2011