In her New York Times “Well”
blog of April 13, 2015, physician Abigail Zuger comments upon “Quantifying
Tests, Instead of Good Care”. She discusses a variety of factors that lead
to physicians ordering more and more tests. In part, this is the simply the result
of the advance of technology and thus the profusion of tests that can be done -- laboratory tests, imaging (like x-rays and
their ever more complex cousins), and even parts of the physical examination (“Yes, little blood pressure cuff over there
in the corner, that means you”) -- which sometimes can be seen as meaning they should be done. Other factors are about
money. The tests cost money, a
negative for patients and insurers, but they
make money for the laboratories and imaging facilities and the hospitals
which often own them, and frequently employ the physicians doing the ordering. Dr.
Zuger notes that “Ordering tests, chasing down and interpreting results, and
dealing with the endless cycle of repeat testing to confirm and clarify
problems absorb pretty much all our time.”
Another impetus is our desire – patients and physicians
alike – to find out what is wrong when there is something wrong. Or, when there
is nothing really wrong, to perhaps prevent later disease by finding something
hidden lurking inside. There are all these tests we can get! The patient may have
had many of them before, ordered by another provider, or know people who have
had them. They hope that something
will give them an answer. The doctor may feel that there may be an answer out
there that s/he might miss if a test is not ordered, or if s/he is a primary
care physician that a specialist might order these tests so maybe we should do
it first; after all, it sometimes seems as if one thing specialists do when we
refer patients to them is order a bunch of tests that we could have. Or, and
this is a big focus of Dr. Zuger, that their “quality ratings” may suffer if
s/he doesn’t order these tests.
Quality ratings are measures of things that doctors should
do (or, sometimes but more rarely, should not
do) for patients with certain conditions or complaints; increasingly,
insurers, employers, and third-party groups are assessing the quality of care
that a physician delivers in this way. Are these recommendations not based on
evidence? In many cases, they are. For prevention, the US Preventive Services
Task Force assesses the degree to which tests may be indicated or not for
different people, often based upon their age and sex. It gives them ratings: ‘A’
is strongly recommended based on good evidence, ‘B’ means there is some, but
weaker, evidence to support doing it, ’C’ means there is conflicting evidence
and patient preference should be taken into account, ‘D’ means not recommended
(might even be harmful), and ‘I’ means insufficient evidence to assess. A smart
phone app, ePSS, can be
downloaded by anyone; put in age and sex and it tells you which preventive
tests are recommended.
Of course, not all doctors do all the recommended screening
tests, and frequently they do tests that are not recommended (e.g., PSA
to screen for prostate cancer) or more frequently than recommended (Pap
smears to screen for cervical cancer), or in people for whom the test is
not recommended (mammograms
in younger women). When it comes to diagnostic testing rather than screening,
looking for the cause of something when the patient is actually ill, there is
even less consensus, and often a prevailing attitude of “more (testing) is
better”. One effort to combat this is the Choosing Wisely campaign begun by the
American Board of Internal Medicine Foundation. This campaign asked specialty
societies to identify 5 or more commonly-done tests or interventions in their
specialty that should not be done. However,
the same recommendations are not always endorsed by every relevant
organization. For example, the American Academy of Family Physicians recommends
“Don’t
do imaging for low back pain within the first six weeks, unless red flags are
present.” Great, but neither the American College of Radiology nor the
American Academy of Orthopaedic Surgeons, arguably the groups that could make
money from this, has such a recommendation.
And then there is the risk. Some of the tests receiving USPSTF
‘D’ recommendations are more than not helpful; they can lead to harm, and this
is even more true of the many potential tests that can be done looking for
disease. Discussing the work of a collaboration at the Dartmouth Medical School
that looks at the utility of tests, Dr. Zuger notes that such iconic treatments
as controlling blood pressure can lead to bad outcomes in many older people
where the benefits (avoiding stroke and other complications) begin to be
outweighed by the risks: “One study
found that nursing home residents taking two or more effective blood pressure
drugs did remarkably badly, with death rates more than twice that of their
peers. In another, dementia patients taking blood pressure medication with
optimal results nonetheless deteriorated mentally considerably faster. Yet no
quality control system that I know of gives a doctor an approving pat on the
head for taking a fragile older patient off meds.”
This is just the tip of the iceberg. Tests cost money, and
often show results that lead to more tests, and then maybe to procedures
(biopsies, for example) that maybe show abnormalities that lead to bigger
interventions. And, sometimes these interventions are life-saving, but not
always. Or maybe, even, not often. And
they do often have side effects, some of which are not insignificant. The
person in whom a series of tests identifies cancer and is then treated and then
survives is almost always grateful for the testing and the treatment, although
in many cases they would have survived just the same with no treatment, and
without the costs both in dollars and in side effects. The classic example is prostate
cancer, where the evidence of any treatment making a difference in survival is
weak at best; it is either a devastating disease from which one dies,
painfully, or more commonly a benign condition that one dies with but not from
but which treatment seems to have little influence on. Except for the cost, and
the non-trivial side effects of impotence, incontinence, and the effects of
radiation on the rectum.
Increasingly, data is showing that much breast cancer is
similar. As discussed in my December 2012 blog post “More
on mammography: just because you don't like the results doesn't make research
junk science”, a large study by Bleyer and Welch showed that, with new and
more sensitive mammographic screening, many more women are being diagnosed with
early-stage breast cancer. However, despite treatment, we are not seeing
anything like that reduction in late-stage breast cancer, which means most of
those early stage cancers would not have progressed at all. And yet every woman
diagnosed and treated sees herself as a survivor who has been cured, even in
those cases where progression would not have occurred. In his wonderful recent New Yorker article “Overkill”
(May 11, 2015), Atul Gawande notes that we treat all “cancer” as if it were
rabbits in a pen who have to be chased down before they escape, when in fact
many cancers are “birds” that have flown away and are gone before we can do
anything and many others are “turtles” who are not going anywhere whatever we
do.
The goal of medical care is now to achieve the “Triple Aim”
of high quality, patient satisfaction, and lower cost. As with many things that
come in threes, it is not that hard to achieve two but very challenging to
achieve all three. Patients satisfaction is important, but not at any cost.
Cost control is good, but not if it seriously limits quality. One place to
start, then, is with quality, and specifically not doing what is useless or even harmful as assertively as we do what is likely to be of value.
And, of course, to make sure that it is the disease or risk
of disease that determines what tests are done, not people’s insurance or socioeconomic
status, ethnicity, gender or personality.
