Issue 38 / 10 October 2011

DOCTORS could improve patient care while spending less, by minimising the use of certain expensive, unnecessary clinical activities, new research suggests.

The US Good Stewardship Working Group has created lists of the top 5 overused clinical activities across three primary care specialties (paediatrics, internal medicine, and family medicine).

In new research, they have examined the frequency and costs of these activities, which were believed to be common in primary care but of little benefit to patients. The findings were published in Archives of Internal Medicine. (1)

Prescribing expensive (non-generic) statins accounted for $US5.8 billion or 86% of the US$6.76 billion wasted each year on unnecessary clinical activities in primary care in the US.

“Our data suggest that considerably more work is needed to reduce the costs associated with brand name statin use”, the researchers said.

Ordering a complete blood cell count for patients undergoing a general check-up was the most common activity and cost $US32.7 million annually.

Prescribing antibiotics for children with a sore throat was very common and cost US$116.4 million and ordering a CT, MRI or x-ray for acute back pain racked up US$175.4 million in excess costs.

“Our results also demonstrate that highly prevalent activities with small individual costs can result in large overall costs to the health care system and thus warrant further attention.”

Professor Chris Del Mar, professor of public health at Bond University, Queensland, said costs were not likely to be very different between the two countries, although Australia funded drugs differently.

In the US there is better protection of the pharmaceutical industry and a more open market, whereas in Australia pharmaceuticals are bulk purchased for the population through the PBS.

“Could we be improving quality of care while spending less? For sure”, he said.

“Apart from anything else, we might reduce patient anxiety, reduce our workload, and enable the surplus in time and money … to be spent on people and treatments that really cause benefit.”

The research also found that bone density testing in women younger than 65 years was the least prevalent activity of the top five, but cost $US527 million annually.

Professor Del Mar said doctors often continued doing things that had previously worked, even though outcomes might be identical if they stopped, perhaps because of the natural history of the illness.

“It’s often easy to busy oneself treating a surrogate outcome such as a DEXA scan without stopping to look at the absolute benefit of the management”, he said.

Professor Del Mar said the RACGP’s guidelines for preventive activities in general practice (the Red Book) — of which he is a coauthor — were probably quite effective in helping curtail some unnecessary investigations.

“We often assume, and are sometimes wrong, that patients want us to do something”, he said. “It seems to be especially hard for doctors to adhere to the principle, ‘Don’t just DO something! Stand there!’

“Sometimes we are much better doctors by protecting our patients from too much technology when there isn’t good evidence for its benefit.”

Professor Del Mar said the Australian top five lists were likely to be different because generally fewer investigations, particularly “routine” investigations such as annual ECGs, were undertaken in Australia than in the US.

Associate Professor Lyndal Trevena, of the School of Public Health at the University of Sydney, said an underexplored issue was community attitudes to rational test ordering.

“I think … patients are not aware of the costs of many of these tests and we don’t have any good data on patient expectations or knowledge on this matter”, she said.

“I suspect many GPs are under or feel under pressure from some patients to order tests which can be quite costly to the taxpayer.”

– Cathy Saunders

1. Arch Intern Med 2011; 1 October (online)

 

Posted 10 October 2011

 

6 thoughts on “Spend less, improve patient care

  1. Ken Sleeman says:

    Many pre-op tests in the USA are initiated purely on a basis of being “medical-defensive”. Unfortunately this attitude has spread to Australia. It does require some experience to select appropriate tests, so interns need to be well supervised in pre-admission clinics.
    The practice of some path labs in reporting total auto-analyser results, often with some outliers which have no relevance, may lead to expensive over-investigation.

  2. woolly says:

    A hard issue this one. The opposite side of the coin is all the patients I have seen in the emergency dept who have been UNDER investigated or totally NON investigated (the “pat on the head”, you’ll be right mate ) by GPs. Until they come to me weeks or months later and the scan shows their headaches are a brain tumour or their abdo pain is a pancreatic cancer… that would have been better diagnosed weeks or months ago.

  3. Dr Klaus Stelter says:

    Both Ken Sleeman and “woolly” have parts of the total picture – another issue is that we are bypassing the careful/considered history and probably even an adequate examination of our patients and jumping from symptoms (or no symptoms) straight to investigations. The other danger is (now) that health bureaucrats will limit discretionary investigations – because they have “the evidence” – on what history/examination might make the brain/pancreatic tumour more likely – if this evidence was just shared with the profession we would be better off and not have to practise supermarket or defensive medicine.

  4. Anonymous says:

    Patients are made aware of the cost of the medications that they use. Admittedly the MBS, especially in relation to pathology is much more complicated than the PBS but patients (and doctors) should be made aware of the costs that they incur.

  5. Anonymous says:

    Proper clinical assessment can obviate the need for expensive unnecessary investigations. The current medical training is focussed more on investigational techniques rather than deveoping clinical skills.

  6. Anonymous says:

    A good example is over ordering blood tests in hospital. For instance, it is not uncommon to see CRPs done twice a day, or FBEs done daily with no clear clinical indication. Also, there is the thoughtless ordering of MBA20 by registrars and consultants when all we’re interested in is the potassium (or whatever one or 2 things you can think of). These senior staff then tell off the junior staff who are trying to be judicious in ordering tests!

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