It is no longer news that Americans, and older Americans in
particular, get more routine screening tests than they need, more than
are useful.
Prostate tests for men over 75,
annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.
Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.
The
difference, in brief: Screening tests are performed on people who are
asymptomatic, who aren’t complaining of a health problem, as a way to
detect incipient disease. We have heard for years that it is best to
“catch it early” — “it” frequently being cancer — and though that turns
out to be only sometimes true, we and our doctors often ignore medical
guidelines and ongoing campaigns to limit and target screening tests.
Diagnostic
tests, on the other hand, are meant to help doctors evaluate some
symptom or problem. “You’re trying to figure out what’s wrong,”
explained Gilbert Welch, a veteran researcher at the Dartmouth Institute
for Health Policy and Clinical Practice.
For these tests, medical
groups and task forces offer many fewer guidelines on who should get
them and how often — there is not much evidence to go on — but there is
general agreement that they are not intended for routine surveillance.
But
a study using a random 5 percent sample of Medicare beneficiaries —
nearly 750,000 of them — suggests that often, that is what’s happening.
“It begins to look like some of these tests are being routinely repeated,
and it’s worrisome,” said Dr. Welch, lead author of the study just
published in The Archives of Internal Medicine. “Some physicians are
just doing them every year.”
He is talking about tests like
echocardiography, or a sonogram of the heart. More than a quarter of the
sample (28.5 percent) underwent this test between 2004 and 2006, and
more than half of those patients (55 percent) had a repeat
echocardiogram within three years, most commonly within a year of the
first.
Other common tests were frequently repeated as well. Of
patients who underwent an imaging stress test, using a treadmill or
stationary bike (or receiving a drug) to make the heart work harder,
nearly 44 percent had a repeat test within three years. So did about
half of those undergoing pulmonary function tests and chest tomography, a
CAT scan of the chest.
Cystoscopy (a procedure in which a viewing
tube is inserted into the bladder) was repeated for about 41 percent of
the patients, and endoscopy (a swallowed tube enters the esophagus and
stomach) for more than a third.
Is this too much testing? Without
evidence of how much it harms or helps patients, it is hard to say — but
the researchers were startled by the extent of repetition. “It’s
inconceivable that it’s all important,” Dr. Welch said. “Unfortunately,
it looks like it’s important for doctors.”
The evidence for that?
The study revealed big geographic differences in diagnostic testing.
Looking at the country’s 50 largest metropolitan areas, it found that
nearly half the sample’s patients in Miami had an echocardiogram between
2004 and 2006, and two thirds of them had another echocardiogram within
three years — the highest rate in the nation.
In fact, for the
six tests the study included, five were performed and repeated most
often in Florida cities: Miami, Jacksonville and Orlando. “They’re
heavily populated by physicians and they have a long history of being at
the top of the list” of areas that do a lot of medical procedures and
hospitalizations, Dr. Welch said.
But in Portland, Ore., where
“the physician culture is very different,” only 17.5 percent of patients
had an echocardiogram. The places most prone to testing were also the
places with high rates of repeat testing. Portland, San Francisco and
Sacramento had the lowest rates.
We often don’t think of tests as
having a downside, but they do. “This is the way whole cascades can
start that are hard to stop,” Dr. Welch said. “The more we subject
ourselves, the more likely some abnormality shows up that may require
more testing, some of which has unwanted consequences.”
Properly
used, of course, diagnostic tests can provide crucial information for
sick people. “But used without a good indication, they can stir up a
hornet’s nest,” he said. And of course they cost Medicare a bundle.
An accompanying commentary,
sounding distinctly exasperated, pointed out that efforts to restrain
overtesting and overtreatment have continued for decades. The commentary
called it “discouraging to contemplate fresh evidence by Welch et al of
our failure to curb waste of health care resources.”
It is hard
for laypeople to know when tests make sense, but clearly we need to keep
track of those we and our family members have. That way, if the
cardiologist suggests another echocardiogram, we can at least ask a few
pointed questions:
“My father just had one six months ago. Is it
necessary to have another so soon? What information do you hope to gain
that you didn’t have last time? Will the results change the way we
manage his condition?”
Questions are always a good idea. Especially in Florida.
Sources :
Paula Span.com