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Repeat testing common among Medicare patients

By Genevra Pittman

NEW YORK (Reuters Health) - In a new study, up to half - or more - of older adults on Medicare who had a heart, lung, stomach or bladder test had the same procedure repeated within three years.

Those tests typically aren't supposed to be routinely repeated, researchers said. For some of them, such as echocardiography and stress tests for heart function, there are recommendations specifically against routine testing.

"What we were struck by is just how commonly these tests are being repeated," said Dr. H. Gilbert Welch, lead author of the report from the Dartmouth Institute for Health Policy and Clinical Practice in Hanover, New Hampshire.

"Either these patients continually develop new problems or there are doctors who routinely repeat tests."

Extra testing can burden the health care system with costs and may lead to incidental findings and unnecessary treatment for patients, Welch told Reuters Health.

He and his colleagues looked at the use of six kinds of test - echocardiography (ultrasound of the heart), stress tests, lung function tests, chest CT scan, cystoscopy (examination of the bladder with a scope) and upper endoscopy (examination of the upper GI tract) - among 743,478 older adults with fee-for-service Medicare coverage.

All of those tests are diagnostic, meaning they would typically be done on people with symptoms to help doctors make a diagnosis. They range in price from about $200 to over $1,000.

Between 2004 and 2006, anywhere from seven percent (cystoscopy) to 29 percent (echocardiography) of the Medicare beneficiaries in the study had each of those tests at least once.

And those exams were all commonly repeated: 35 percent of the people who had an upper endoscopy had another within three years. Of those who had an echocardiogram, 55 percent had a repeat echocardiogram. Repeat rates for the other tests fell somewhere in between.

The average time between multiple tests was anywhere from four to 14 months, according to findings published Monday in the Archives of Internal Medicine.

Welch said the only time repeat tests make good medical sense is when patients develop a new set of symptoms that doctors want to check out after the first test. But for physicians, financial incentives typically support more frequent testing, no matter what the purpose.

With an echocardiogram, for example, "If the cardiologist is the one that's ordering and going to interpret it… there probably is a financial incentive to overuse that test," said Dr. Rachel Werner, a health policy researcher from the University of Pennsylvania in Philadelphia.

"The fact is, we are paid more to do more," Welch said. And that's not always the best thing for the people getting tested.

"Patients have understood the importance of not having unnecessary medications. But I think the general sense is, ‘Well, a diagnostic test can never hurt you,'" Welch said.

But, he added, "Whenever we do a diagnostic test, we're at risk to be distracted by an incidental finding." Those findings can lead to more tests and possibly unnecessary treatments.

"Patients get in this cascade of events of new things to worry about and subsequent procedures," Welch said.

His team also found that metropolitan areas that did more of the initial diagnostic tests to begin with also had higher rates of re-testing.

Werner, who was not involved in the new study, said policies written into the Affordable Care Act will emphasize outcomes over number of procedures, in an attempt to balance quality and cost.

In the meantime, she recommended the Choosing Wisely initiative website (), which has lists compiled by medical specialist societies of particular tests that patients should question.

"You should always speak up to your physician," Werner told Reuters Health. "It's very hard often for patients to do that, because of the dynamics of the relationship, but they should always feel that that's part of their right, to be able to question what their physician is doing."

SOURCE: http://bit.ly/MbBLbb Archives of Internal Medicine, online November 19, 2012.

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