Amir Qaseem, MD, PhD, MHA; Patrick Alguire, MD; Paul Dallas, MD; Lawrence E. Feinberg, MD; Faith T. Fitzgerald, MD; Carrie Horwitch, MD, MPH; Linda Humphrey, MD, MPH; Richard LeBlond, MD; Darilyn Moyer, MD; Jeffrey G. Wiese, MD; Steven Weinberger, MD
Disclaimer: This high-value care advice is a guide only and may not apply to all patients and all clinical situations. Thus, this advice is not intended to override clinicians' judgment.
Acknowledgment: The authors thank Dr. Douglas K. Owens for his critical review and comments.
Financial Support: Financial support for the development of this paper comes exclusively from the American College of Physicians operating budget.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2550.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Qaseem, Alguire, and Weinberger: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Dallas: Virginia Tech Carilion School of Medicine and Research Institute, 1906 Belleview Avenue, Roanoke, VA 24014.
Dr. Feinberg: University of Colorado Health Sciences Center, 1635 Aurora Court, 13001 East 17th Place, Aurora, CO 80013.
Dr. Fitzgerald: University of California, Davis, Health System, 4150 V Street, Suite 2400, Sacramento, CA 95817.
Dr. Horwitch: Virginia Mason Medical Center, University of Washington, 1100 Ninth Avenue, Seattle, WA 98111.
Dr. Humphrey: Oregon Health & Science University, 3710 SW U.S. Veterans Hospital Road, Portland, OR 97201.
Dr. LeBlond: University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242.
Dr. Moyer: Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140.
Dr. Wiese: Tulane University Health Sciences Center, 1430 Tulane Avenue, New Orleans, LA 70112.
Author Contributions: Conception and design: A. Qaseem, P. Alguire, P. Dallas, F.T. Fitzgerald, D. Moyer, R. LeBlond, S. Weinberger.
Analysis and interpretation of the data: A. Qaseem, P. Dallas, L.E. Feinberg, F.T. Fitzgerald, C. Horwitch, L. Humphrey, D. Moyer, J.G. Wiese, S. Weinberger.
Drafting of the article: A. Qaseem, P. Alguire, P. Dallas, D. Moyer, S. Weinberger.
Critical revision of the article for important intellectual content: A. Qaseem, P. Alguire, P. Dallas, L.E. Feinberg, F.T. Fitzgerald, L. Humphrey, R. LeBlond, D. Moyer, J.G. Wiese, S. Weinberger.
Final approval of the article: A. Qaseem, P. Alguire, L.E. Feinberg, F.T. Fitzgerald, C. Horwitch, L. Humphrey, R. LeBlond, D. Moyer, J.G. Wiese, S. Weinberger.
Provision of study materials or patients: A. Qaseem.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, P. Alguire.
Collection and assembly of data: A. Qaseem, P. Alguire, P. Dallas, L.E. Feinberg, F.T. Fitzgerald, C. Horwitch, D. Moyer, J.G. Wiese, S. Weinberger.
Reader Survey: Which testing scenarios are low value?
Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests—meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.
Table. Clinical Situations in Which a Test Does Not Reflect High-Value Care
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Zackary D.Berger, Assistant Professor
Johns Hopkins University School of Medicine
January 17, 2012
Qaseem et al. provide an important first step - where do we go from here?
To the editors,
The Good Stewardship Working Group of the National Physicians Alliance applauds Qaseem et al. (1) for their identification of screening and diagnostic tests which, when misused, discourage high-value, cost- conscious care. Physicians should be at the forefront of identifying inappropriate procedures, and such a consensus list represents an important contribution to this effort.
As was mentioned in the accompanying Annals editorial (2), our group used a similar consensus method to agree on "top 5" lists of inappropriate testing in several specialties, including internal medicine. (3) Based on our experience and the present Annals article, two further steps come to mind.
First, professional organizations should continue to identify inappropriate procedures (perhaps through regular member polling on-line), update and disseminate such lists, and bring them to the attention of policy makers. Second, our health care system should be realigned to reduce such waste. How to accomplish these steps is a topic for further discussion, which Qaseem et al. have made possible.
Zackary Berger, MD, PhD Johns Hopkins General Internal Medicine for the Good Stewardship Working Group
1. Qaseem A et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med 2012;156:147- 149.
2. Laine C. High-Value Testing Begins With a Few Simple Questions. Ann Intern Med 2012;156:162-163.
3. Good Stewardship Working Group. The "Top 5" Lists in Primary Care: Meeting the Responsibility of Professionalism. Arch Int Med 2011;171(15):1385-1390.
Patrick O.Oben, Resident
John H Stroger Hospital, Chicago, IL
January 18, 2012
Thank you for this thought-provoking work. It rightfully made me to consider my own ways in the hospital.
I have one suggestion to make for future versions of this work that may increase its clinical impact, at least from my perspective. I would suggest that the methodology of this work and the Suggested Principles address at least some of the major causes of inappropriate use of tests. Observing physician behavior and making suggestions based on observed behavior alone as portrayed in the methodology of this current work seems to leave out, if not underestimate, the value of the causes of these inappropriate clinical behaviors. There are reasons why physicians order lab tests, whether explicit or implicit.(1) If there is an inappropriate action because of a addressable cause, the impact of the suggestion would be considerable greater if it addresses both the observed action and the cause than if it merely suggest what should have been done.
An example is that of one of the minor causes of inappropriate use of tests is defensive medicine, which has been shown to the reason for performing about 5% to 10% of diagnostic tests and resulting in an annual cost of about $9 billion to $18 billion annually in the United States.(2,3,4) Suggesting to an Emergency Department Physician who is inappropriately ordering routine CT angiogram to rule out pulmonary embolism in a low risk patient presenting with chest pain for fear of malpractice lawsuit without professionally addressing the driving cause would clearly have minimal effects. This is just an example to illustrate the cause-behavior-suggestion proposal above.
1. Wertman BG, Sostrin SV, Pavlova Z, Lundberg GD.Why do physicians order laboratory tests? A study of laboratory test request and use patterns. JAMA. 1980 May 23-30;243(20):2080-2.
2. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005; 293:2609-17.
3. Defensive Medicine and Medical Practice. Publication OTA-H-602. Washington, DC: Office of Technology Assessment, US Congress, Jul 1994.
4. Anderson RE. Billions for defense. Arch Intern Med. 1999; 159:2399 -402.
Erik A.Wallace, MD, Associate Professor, John H. Schumann, MD, Associate Professor, University of Oklahoma School of Community Medicine
University of Oklahoma School of Community Medicine
January 19, 2012
Appropriate Use of Screening and Diagnostic Tests to Foster High Value, Cost-Conscious Care
TO THE EDITOR: As discussed by Qaseem et al (1), unnecessary testing ordered by physicians contributes to a significant proportion of increased health care spending. Although we agree that the 37 tests listed do not reflect high-value care, some of these tests, plus additional low-cost, low-value tests, are available for purchase by patients through commercial companies. These tests, including a variety of blood tests and ultrasounds, are being marketed to the general public as a way to find disease before symptoms present so that patients can avoid experiencing a catastrophic illness. Although patients can assess their risk for illness and whether a test is "indicated, " patients are encouraged to "consider" purchasing tests despite being asymptomatic and lacking other characteristics that would meet indications for the test based on current published guidelines. For example, if a patient is less than age 50 years and smokes but has no other clinical symptoms or risk factors, they are asked to "consider" purchasing an ultrasound of the carotid arteries and aorta (2), although the USPSTF clearly states that these tests, with moderate to high certainty, have "no net benefit or that the harms outweigh the benefits" in this particular patient (3,4). Also, the more tests that patients can purchase as part of a package, they more money they can theoretically "save."
In the accompanying editorial, Laine (5) provides a list of questions to help physicians judiciously order tests. This is certainly helpful if patients ask their physician beforehand whether they should purchase commercial screening tests. However, if patients have already purchased these tests and have obtained an abnormal result, then they likely have a different set of expectations and may be more insistent on additional testing or treatment that will certainly add additional cost, and potentially result in harm.
"Patient expectation can be a powerful force in promoting testing." (5) Commercial companies who sell unnecessary screening tests are creating a false sense of patient expectations that catastrophic illness can be avoided without ethically discussing the potential risks and lack of benefit of these tests. Direct-to-consumer advertising of commercial screening tests makes the goal of practicing high-value, cost-conscious care even more challenging.
1. Qaseem A et al. Appropriate Use of Screening and Diagnostic Tests to Foster High Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147- 149.
2. Life Line Screening. The power of prevention. http://lifelinescreening.com. Accessed on January 19, 2012.
3. U.S. Preventive Services Task Force. Screening for Carotid Artery Stenosis: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2007; 147:854-859.
4. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm. Ann Intern Med. 2005; 142:198-202.
5. Laine C. High-Value Testing Begins With a Few Simple Questions. Ann Intern Med. 2012;156:162-163.
Ronald N.Levy, MD
January 31, 2012
Fuller Disclosure of Health Benefits Needed
To the Editor:
Regarding your criticism of diagnostic tests, how about fuller disclosure on the question of "whether a test provides health benefits that are worth their cost?"
Postitive test results can save lives so should critics of tests consider not only test costs but also disclose what they estimate to be the value of lives saved?
Negative test results can in many cases reduce worry and increase quality of life so should "less testing" advocates disclose what value they ascribe to fear relieved and QoL enhanced?
Telling a patient "you don't need" a requested diagnostic test is like saying "you don't need a tranquilizer, mood elevator or annual check- up: if the patient doesn't die, the test wasn't needed for survival but is this the quality of medicine that doctors would want for their own families?
Just as hospitals can seem to "save" money by reducing staff and equipment, doctors can "save" by reducing tests but should doctors disclose to patients that such reductions may reduce overall survival and reduce peace of mind?
If America's hospitals sometimes keep on life support for days many hopelessly comatose patients including some who are brain dead, should these hospitals withold tests that could save lives and mental strain of brain-alive patients, providing drug-free tranquility?
If hospitals bear the cost of providing space for chapels and comfortable waiting rooms despite no clinical proof that these benefits are "worth their cost," should hospitals consider that if expert insurers are willing to pay and informed patients are eager for an annual test, the tests also provide benefits?
Should guideline groups like NCCN reason that if patients have a choice of whether to have surgery or other therapy that may help them, patients should also be allowed diagnostic tests that may also help and cost much less?
This patient question-"Can you reassure me that we have explored all the options" is suggested by The Wall Street Journal of 1/17/12 under the headline, "What to Ask When Seeking a Second Opinion." Would it make sense for diagnostic options to be presented by the first doctor entrusted with a patient's life and peace of mind?
Respectfully, Ronald N. Levy
Frank J.Rybicki, MD, PhD, Michael A. Bettmann, MD, Paul A. Larson, MD, Harvey L. Neiman, MD
February 2, 2012
The paper by Qaseem et al, "Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care" (1), identifies common clinical situations for which screening and diagnostic tests may have limited utility. The American College of Radiology (ACR) enthusiastically supports the work of the American College of Physicians (ACP) in this arena. The ACR Appropriateness Criteria? (ACR AC) are clinical imaging guidelines that begin by asking: if I think an imaging study may be valuable in this specific clinical setting, which, if any, should be selected? The 20 ACR AC organ system-based panels span diagnostic and interventional radiology and radiation oncology; the AC use the best available peer-reviewed evidence and widely accepted, reproducible methodology to cover 850 specific clinical variants, and are freely available online (2). Each panel is composed of both private practice and academic radiologists with diverse representation in all relevant modalities, supplemented by non-radiologist representatives from other societies. Each variant is updated at no longer than two-year intervals.
Based on our experience with producing and deploying the ACR AC, we are not surprised that 20 of 37 highlighted situations are related to imaging (13 primarily in radiology, 7 in cardiology). All of these clinical situations can be mapped to specific ACR AC. We believe that more widespread implementation of these guidelines will foster high-value, cost -conscious care.
The clinical situations that focus on imaging have varying complexity that influences implementation. One good example is the evaluation of patients with low back pain. The most recent (October 2011) ACR AC release (2) includes five variants of this topic. At one end of the spectrum, no imaging is appropriate for patients without specific, defined "red flags". Conversely, for patients with specific risk factors, such as cauda equina syndrome, or advanced age and osteoporosis, specific imaging tests are usually appropriate. The use of sound evidence-based clinical guidelines in this and other examples discussed can and should direct practice to more rational, less costly approaches that both improve resource utilization and limit unnecessary radiation exposure, two major public health concerns.
Qaseem et al thoughtfully and meaningfully identify at-risk clinical situations that require high-quality guidelines to encourage appropriate use. The ACR AC provide the best available guidance for imaging studies. The ACR is committed to collaboration and distribution of specific guidelines for imaging that improve cost conscious appropriate use of imaging, since both over- and inappropriate use occur. We enthusiastically support the ACP effort to promote good stewardship of finite health care resources while improving care.
Frank J. Rybicki, MD, PhD Michael A. Bettmann, MD
Paul A. Larson, MD
Harvey L. Neiman, MD
1. Foster High-Value, Cost-Conscious Care. Ann Intern Med 2012 Jan 17;156(2):147-149. PMID: 22250146.
2. American College of Radiology. ACR Appropriateness Criteria?http://www.acr.org/SecondaryMainMenuCategories/quality safety/app criteria.aspx
James R.Johnson, MD
Infectious Diseases, Minneapolis VA Medical Center
February 7, 2012
Urinalysis and Urine Culture Testing Omitted
To the editor:
The clinical situations identified by Qaseem et al. in which a test does not reflect high-value care omitted what may be the most frequently misused infectious disease screening tests of all, the humble urinalysis and urine culture . Such testing is almost always inappropriate when performed in patients without clinical manifestations of overt urinary tract infection, especially if positive results are interpreted as indicating the presence of urinary tract infection in need of treatment [2, 3]. Although the cost per test cost is low, the enormous numbers result in substantial aggregate costs. More importantly, unnecessary and potentially toxic antimicrobial therapy often follows the detection of (clinically irrelevant) asymptomatic pyuria or bacteriuria, which are quite common, especially among elderly, functionally impaired, and urinary -catheter-using patients [2, 3]. It would be of interest to know whether the work group considered these tests for inclusion in their list but rejected them (and if so, why), or did not even consider them, which would not be surprising, given their ubiquity as unrecognized drivers of gratuitous antimicrobial therapy.
James R. Johnson, MD Infectious Diseases (111F) Minneapolis VA Medical Center
1. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese JG, Weinberger S. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med 2012;156:147-9.
2. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.
3. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambyah PA, Tanke P, Nicolle LE. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63.
I have received research support from Merck, Inc.; Rochester Medical Group; and Syntiron.
Robert C.Schutt, Resident
University of Virginia
The Evolving Role of Brain Natriuretic Peptide in the Management of Acute Decompensated Heart Failure
I would like to commend Qaseem et al. (1) on their recent efforts to identify diagnostic tests that are used in situations where they are not likely to be of high value. One of the clinical situations (#9) that the working group felt did not represent high value care was obtaining a brain natriuretic peptide level (BNP) on the initial evaluation of a patient who presents with the typical findings of heart failure.
Although BNP is classically used to help differentiate symptom etiology when uncertainty exists, there is an emerging and exciting role for BNP use in helping guide management of acute decompensated heart failure. Two recent large studies found that both the absolute value of BNP at discharge (2) and the percentage reduction during hospitalization (3) predicted death or readmission in patients admitted with heart failure and is superior to clinical variables alone. This recent evidence combined with prior work suggests that measurement of BNP may have an important role as an element of discharge criteria for patients admitted with acute decompensated heart failure.(4) In fact, BNP may be a significantly more cost-effective alternative when compared with echocardiography for risk stratification in patients admitted with heart failure.(5)
Although use the of this biomarker solely to confirm the diagnosis of heart failure in a patient where no diagnostic uncertainty exists is clearly not cost conscious, it is important to at least be aware that there is an evolving role for this biomarker in the management of acute decompensated heart failure and there is promising research that suggests an active role for this biomarker in potentially reducing readmissions for heart failure.
Rob Schutt, MD (email@example.com)
Department of Medicine
University of Virginia
1. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156(2):147-9.
2. Kociol RD, Horton JR, Fonarow GC, Reyes EM, Shaw LK, O'Connor CM, et al. Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE -HF) linked to Medicare claims. Circ Heart Fail. 2011;4(5):628-36.
3. Di Somma S, Magrini L, Pittoni V, Marino R, Mastrantuono A, Ferri E, et al. In-hospital percentage BNP reduction is highly predictive for adverse events in patients admitted for acute heart failure: the Italian RED Study. Crit Care. 2010;14(3):R116.
4. Caldwell MA, Howie JN, Dracup K. BNP as discharge criteria for heart failure. J Card Fail. 2003;9(5):416-22.
5. Dokainish H, Zoghbi WA, Ambriz E, Lakkis NM, Quinones MA, Nagueh SF. Comparative cost-effectiveness of B-type natriuretic peptide and echocardiography for predicting outcome in patients with congestive heart failure. Am J Cardiol. 2006;97(3):400-3.
AmirQaseem, MD, PhD, MHA, Patrick Alguire, MD, Steven Weinberger, MD, American College of Physicians
American College of Physicians, 190 N. Independence Mall W. Philadelphia, PA 19106
March 6, 2012
Overused Diagnostic and Screening Tests
We thank Dr. Rybicki and colleagues and Dr. Berger for their comments and their encouragement for this effort . We strongly agree that professional organizations have an opportunity to play a critical role in reducing health care costs while maintaining, if not improving, the quality of care by educating physicians to avoid overuse and misuse of care. The American College of Radiology (ACR) and the National Physicians Alliance have indeed been leaders in this effort through the development of the Appropriateness Criteria for imaging studies and the efforts of the Good Stewardship Working Group in identifying several "top 5 lists" [2,3].
We believe Dr. Johnson's example of urinalysis and urine culture as overused tests is a good one that likely should have been included on our list. The list is not an exhaustive one, and a goal in developing it was to promote thoughtful discussions among all stakeholders (clinicians, patients, policy makers, etc.) regarding this issue. Consequently, we are pleased that the article has stimulated identification of other areas of screening and diagnostic testing that we missed.
In response to Mr. Levy, we must stress that our primary goal is to promote the best care for patients, which means providing testing and treatment that is of value, when weighing the benefits against the harms and costs of a test or treatment. Saying that "negative test results can in many cases reduce worry" is looking at only one side of the coin, as it does not consider the problems posed by false negative as well as false positive tests. This is just one reason why it is incumbent upon physicians to use the best available evidence and for patients to be informed partners in decision-making.
Authors: Amir Qaseem, MD, PhD, MHA American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
Patrick Alguire, MD American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
Steven Weinberger, MD American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106
1. Qaseem A, Alguire P, Dallas P, Feinberg L, Fitzgerald F, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese J, Weinberger S. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012; 156: 147-149.
2. American College of Radiology. ACR Appropriateness Criteria. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/Overview.aspx
3. Good Stewardship Working Group. The "top 5" lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171:1385-1390.
Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, et al. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147-149. doi: 10.7326/0003-4819-156-2-201201170-00011
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