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Transparency and awareness

Increasing transparency and awareness of the cost of investigations among providers and patients is important if we are to be effective gatekeepers. Physicians recognize that their knowledge about the cost of tests is poor and report that better knowledge would likely change their ordering habits.² Costs of investigations are increasing out of proportion to other health care costs,³ in part owing to an estimated 30% to 40% of all tests (and 20% to 95% of selected tests) being ordered unnecessarily.⁴ In one study, ordering inappropriate tests led to a mean (SD) unnecessary cost of $66.53 ($66.76) per periodic health maintenance visit.⁵ It is estimated that £1 billion is spent annually on unnecessary tests in the United Kingdom.⁶

Every day physicians go on multiple blind shopping sprees, racking up health care expenses with little awareness of the costs to the system. Simply ordering a “routine” CBC ($10.96 + $15.62 = $26.58) costs almost as much as the physician visit itself. A simple, but often unnecessary, urine “R&M, C&S” [routine and microscopy, culture and sensitivity] will cost $61.39. A serum pregnancy test is $30.36. Blood type and antibody screening, often repeated several times during each pregnancy, costs $138.32.¹

“Often physicians order tests, treatments and procedures despite strong evidence that they may not help, and may even harm, patients.”⁷ Ordering investigations is quicker and easier than doing a thorough history and physical. It provides us (and patients) with the sense that something is being done and it gives time for many self-limited conditions to resolve. Although studies report no correlation between volume of tests ordered and malpractice suits, many physicians continue to assume that by ordering more tests, the risk of “missing something” will decrease.⁷ Academic environments, where practice patterns are learned, can subtly reinforce inappropriate ordering behaviour by rewarding trainees perceived as being “thorough.”⁸ These hard-to-change habits, coupled with patient expectations, lead many completely healthy patients to undergo annual batteries of 20 or more laboratory tests, even though evidence-based screening guidelines recommend very few, if any, routine investigations. More and more, disease-specific guidelines recommend earlier screening, diagnosis of “pre-disease,”⁸ routine “monitoring” (not necessarily evidence-based) for those “diagnosed,” and even incentives for doctors who comply, whether or not the patient will actually benefit from the tests.⁷

Improving ordering practices

Incorporating costs of tests into laboratory requisitions or electronic medical records has been shown to reduce rates of investigations by 27% to 36%.^9,10 Electronic medical records could incorporate an “Add to Cart” feature that could tally costs being incurred during a visit as tests are ordered. This might be particularly effective if combined with other strategies that have been shown to help physicians translate evidence-based recommendations into ordering practice. One of the most promising of these appears to be point-of-ordering, electronic clinical decision support systems, which can reduce inappropriate ordering by up to 28%.^6,11 Restrictive guidelines dictating appropriate timing and indications for such investigations as vitamin D ($61.32), prostate-specific antigen ($32.95), and erythrocyte sedimentation rate ($10.61) measurements are another strategy. In Ontario, it was predicted that simply restricting the use of vitamin D testing would save $64 million per year.¹² Although some physicians dislike such regulation because it is perceived as a threat to autonomy, others believe that it does “relieve family doctors from many debates with patients about services with high costs but no clinical benefit.”¹³ Audit and feedback programs have also had some success,⁷ such as in British Columbia, where physicians are provided with practice profiles comparing them with their peers in terms of rates of investigations, referrals, and so on. The now widely promoted Choosing Wisely program is an excellent educational resource for clinicians and patients. For family physicians, Choosing Wisely recommends ... avoiding routine pre-op CXRs [chest x-rays], head CTs [computed tomography] for headaches, imaging for low back pain without red flags, Pap smears except in target age group 21–65, unnecessary labour inductions, EKGs [electrocardiograms], exercise stress tests and daily monitoring of CBCs and chemistries in hospital.⁸

Tremendous opportunity

While Canadians bemoan the ever increasing and apparently unsustainable costs of health care, physicians should remember that virtually all of these costs, beyond the patient-initiated visit, are physician driven. This gives each one of us a tremendous opportunity to control costs without negatively affecting patient care. By becoming more knowledgeable about investigations and their cost implications and carefully considering each click, we can be more confident that each item we “add to cart” will be appropriate.