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Online tool reduces inappropriate medical tests

By Trevor Stokes

NEW YORK (Reuters Health) - A web-based decision-making tool that alerts heart doctors when diagnostic tests would not be useful for a specific patient can curb wasteful procedures, according to a new study.

"This educational tool helps doctors determine the best test for any particular patient," said lead author Dr. James Min, director of cardiac imaging research at the Cedars-Sinai Medical Center in Los Angeles.

Imaging tests help detect disease and motivate doctors to focus their care, but expensive diagnostic tests can be a financial drain if overused, experts said.

"Even if you didn't care about money, there are reasons not to be tested unnecessarily, including false positive tests and having something found that is not really relevant," said Dr. Gilbert Welch of The Dartmouth Institute for Health Policy & Clinical Practice in New Hampshire, who was not involved in the current study.

That kind of overtesting and overdiagnosis can also lead physicians to pursue treatments that are unnecessary and potentially dangerous for patients, according to Welch.

Researchers noted that in many cases overtesting comes from a physician's inability to keep up with the constantly changing world of diagnostic tools.

In an effort to reduce the use of unnecessary tests, Min and colleagues created an online questionnaire that helped doctors participating in the study to decide whether a test was appropriate.

Physicians took around two minutes to enter details into a web form, then the program gauged the appropriateness of the test against recommendations from the American College of Cardiology (ACC).

The study ran from mid-2010 to early 2011, and the researchers tracked doctors' decision-making at three large cardiology practices in St. Louis. All the patients involved had private insurance through United HealthCare, which agreed to suspend its usual prior authorization requirements to give the doctors free rein to decide which diagnostic tests to give their patients.

During the study, 100 physicians used the decision-aid for 472 heart patients, who were mostly middle-aged men with existing coronary artery disease.

The researchers focused on three common cardiac imaging tests: MRI, as a method to show heart muscle function; stress echocardiography, an ultrasound view of how the heart works when exercised and CT angiogram, a high-resolution X-ray that reveals blood vessel blockage.

Over an eight-month period, inappropriate tests decreased from 22 percent to 6 percent, according to the researchers. During the same period, studies deemed appropriate by ACC criteria increased from 49 percent to 61 percent, Min's team reports in the Journal of the American College of Cardiology.

Reducing unnecessary tests could save a lot of money for the cash-strapped U.S. healthcare system, experts noted. Two of the three heart tests monitored in the study together cost Medicare over $1 billion in 2008 in physician payments alone.

"It's a good study; it reinforces and replicates what others have shown in the same area of clinical decision support for imaging: it can be done and it works," said Dr. Chris Sistrom, a radiologist and health economist with Partners HealthCare, at the University of Florida.

Sistrom was not involved in the current study, but he found a similar trend when he studied a doctor feedback system at Massachusetts General Hospital. The number of inappropriate CT scans decreased from about 20 percent to around 10 percent within a month.

Welch said he expects hospital systems will adopt more of these real-time feedback systems as doctors increasingly use computers to store clinical information and order tests.

"It becomes very useful to have algorithms help physicians," he told Reuters Health.

But he cautioned that such tools will have to strike a balance between giving doctors useful feedback and becoming another time vacuum for busy physicians.

"The balance is not to nickel and dime and overwhelm the physicians with algorithms in the process of what's already a busy job," Welch said.

Dr. Elliot Fishman, professor of radiology, surgery and oncology at Johns Hopkins Hospital, said he sees potential for wider application of decision support tools integrated right into the electronic forms doctors use to order diagnostic tests for a patient.

They would operate something like the feedback and recommendations that pop up when a customer orders a product on Amazon.com, only the programs would guide doctors towards the most appropriate test, Fishman said.

The ideal is always to be able to talk with other doctors for advice, Fishman told Reuters Health, but when that's not possible, technology can be helpful.

"If I'm the patient, anything the physician can do to help me get the right study as fast as possible is a great thing," he said.

SOURCE: http://bit.ly/ZxVjdo Journal of the American College of Cardiology, May 21, 2013.

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