By David E. Winchester, MD, MS; Ryan Meral, BA; Scott Ryals, MD; Rebecca J. Beyth, MD, MSc; Leslee J. Shaw, PhD
JAMA Internal Medicine, June 10, 2013
Myocardial perfusion imaging (MPI) is performed millions of times annually in the United States to assess patients for coronary ischemia. Some have expressed concern that MPI is being used inappropriately, possibly because of self-referral profit motives and professional liability fears. To inform clinicians about situations in which patients are likely to benefit from MPI testing, appropriate use criteria (AUCs) for MPI were developed, last revised in 2009. Prior investigations have applied AUCs to describe the magnitude and patterns of inappropriate testing. Rates of inappropriate testing have ranged from 7% to 24%. We hypothesized that the single-payer environment of the Veterans Affairs (VA) health system, which eliminates self-referral profit motive and limits liability concern, will result in less inappropriate use of MPI.
Results
For all but 4 patients (1%), an indication from the 2009 AUCs could be identified. Study indications were 78% (n = 259) appropriate, 13% (n = 42) inappropriate, and 8% (n = 27) uncertain. The most common inappropriate MPI indications included testing of patients with low pretest probability who could have undergone treadmill electrocardiogram testing (7 patients [16.7% of total inappropriate MPI]) and asymptomatic patients with low coronary heart disease risk (7 patients [16.7% of total inappropriate MPI]).
Discussion
In this retrospective cross-sectional investigation regarding the appropriate use of MPI in a VA health care setting, we observed that a substantial portion of MPI tests were ordered for inappropriate indications. The findings are in contrast to our initial hypothesis but are similar to those of another VA-based investigation, the results of which were published during our investigation.
Our hypothesis was based on unique characteristics of the VA patient care environment. First, no self-referral or profit motives exist. Second, whereas the Federal Tort Claims Act permits medical malpractice lawsuits against federally employed physicians, the substantial majority of claims are resolved through administrative processes.
We did not detect a significant reduction in inappropriate testing in the VA environment, which suggests a lesser role of defensive medicine and self-referral in the inappropriate use of MPI.
Reasons for the observed patterns of ordering MPI are unclear. Conceivably, commonalities in medical training, independent of postgraduate practice environment, could contribute to an exaggerated perception of benefit of MPI in asymptomatic patients and those at low risk of coronary heart disease.
http://archinte.jamanetwork.com/article.aspx?articleid=1696189
Comment:
By Don McCanne, M.D.
This study has two important lessons for health reform advocates – one obvious and the other not so obvious.
The obvious lesson is that “excessive” medical interventions occur even in the absence of greed or fear. In this study, since VA physicians receive no additional income with an increased volume of services – in this case the ordering of myocardial perfusion imaging – the tests that were inappropriate were not done to increase personal income. Also, since most VA malpractice claims are resolved administratively, there is a much lower fear factor that would cause physicians to order tests to reduce the risk of liability lawsuits.
This is good news in the respect that we can dismiss any nefarious motives on the part of most physicians who are recommending interventions that seem to be excessive. Policy corrections should be directed instead to the more important causes of excessive medical interventions.
This leads to the more subtle lesson of this study. What retrospectively is considered to be inappropriate medical management was done by physicians who, at the time, thought that they were doing the right thing for the patient. The policy recommendation that should follow is that we should continue to identify best practices and continue to educate our health professionals on just what those best practices are.
We are already doing this in the form of medical research and continuing medical education. The process can be enhanced by greater reliance on organizations such NICE, Cochrane, and several others. If we want to reduce unnecessary care, our resources should be directed to these efforts rather than being wasted on administrative excesses such as accountable care organizations that rely on feeble measurements that are used to distribute nominal rewards and punishments – not really much of a motivator but more of an insult for dedicated physicians.
Physicians appreciate receiving good information and will use that in their practices. Let’s make better use our public agencies, such as the NIH, that are dedicated to the health of patients, rather than private agencies that jerk our health care dollars around to conform to their business models.
Single payer really would shift the motive from “money first” to “patients and their health first.”