More Tests Do Not Mean Better Care

“I heard the stethoscope is going to be obsolete soon,” a patient said to me the other day. He had heard about some new computerized technology that would replace it. Another patient came in asking about having a whole-body CT scan to be sure he was healthy (he was not aware of the radiation exposure and the risks of such a test).

Technology in health care keeps advancing and becoming more widely available. Yet we must be sure that we use technology appropriately. Technology can be helpful, but it can also be a distraction. And in this era of attempts to reform health care and reduce costs, technology poses added expenses.

Don’t get me wrong; technology can be useful, and it can even save money by helping us to identify and treat conditions early, before complications ensue. Yet we can easily become too reliant on testing, or too casual or automatic about ordering tests, possibly detracting from efficient, patient-centered care. Sure, diagnostic tests are important tools in our kit, but, as NPs, we must use them appropriately and combine them with listening to the patient and performing hands-on examination.

Giving the best care doesn’t always mean ordering the most tests. With a few exceptions, we, as clinicians, are given free reign to request or order almost any diagnostic test(s). Nobody is watching over us, checking to see if the test is really necessary or if the test is the best test for what we want to know. Sometimes, out of fear of missing something (or being sued) or lack of knowledge, we may request more testing or more sophisticated testing than is needed or a test that may not be ideal for the specific problem. Oftentimes, we order a test because a preceptor, colleague, or consultant told us to do it at some point, but we have no evidence to show us it is the best or most appropriate test in that instance.

It’s also easy to think that, because a certain test is covered by insurance, it doesn’t cost anyone anything. There are always costs. Even if a given test is covered for a certain patient, any cost affects overall costs, as well as insurance premiums in the long run. In addition, some tests impose more than just financial burdens. For example, a CT scan exposes a patient to about 50 times as much radiation as a conventional film x-ray. And false-positive findings and incidental findings add costs of their own—emotional costs for the patient and financial costs for society in terms of dollars spent on further workups and evaluations (more tests!).

As NPs, we want to give excellent, cost-effective, compassionate care. How do we know the most appropriate test(s) to order in each case? We must always ask ourselves if the results of the tests we order will affect the treatment we will provide. If we’re not sure, we should have a list of colleagues whose opinions we value and trust and whom we can contact easily. Here are some considerations:

A 47-year-old man presented to my office with flank pain. He had dipstick-positive blood in the urine and classic symptoms of a kidney stone. To evaluate him, should I order the gold-standard CT scan, at a cost of more than $2000, or a  KUB abdominal film at a cost of $200-$300? There is no right or wrong answer. The point is that we need to consider the pluses and minuses of both options. The CT scan will expose the patient to substantial  radiation. The KUB x-ray may miss a stone that is present. Both tests may be covered by insurance, but one costs 10 times as much as the other. What are the implications of not finding something on the less expensive test?

Finally, what does the patient want? My experience has taught me that many patients want to know the options and participate in the decision-making process. I have found myself ordering more KUB x-rays and fewer CT scans in these cases. Patients appreciate receiving less radiation and seeing lower bills (even if they don’t personally pick up the tab). After undergoing the test, they can be informed about symptoms to watch for and report. The CT scan can be ordered as a follow-up if a patient isn’t getting better or a stone isn’t found on the conventional x-ray. Another case involved a 70-year-old man in whom I wanted to rule out myocardial damage. The patient had no health insurance other than Medicare. Again, I wondered about how to evaluate him in an efficient but cost-effective way. A stress echocardiogram would provide useful information about wallmotion abnormalities and heart function. A nuclear stress test would also provide clear information on the condition of his myocardium. The stress echo costs $500 in my community, whereas the nuclear stress test is $1500. Before ordering either test, I called a cardiology colleague whose opinions I value. He recommended doing the less expensive stress echo because, in this particular case, it would provide me with the information I needed at one-third the cost of a nuclear stress test.

On a smaller scale, the difference in price between a basic metabolic panel (BMP) and a comprehensive metabolic panel (CMP) is $20-$30. Do we need the extra tests in the CMP or are we just ordering them because we always do? Do we need a complete blood count at a cost of $25 or will a hemoglobin measure be sufficient, at half the cost?

For many years of NP practice, I was oblivious to the costs of tests and unaware of some of the risks, such as increased radiation exposure, of certain tests. As NPs, we want to provide cost-effective care. We want to help reform health care and lower costs when patients’ welfare isn’t compromised. We can be part of the solution—ordering diagnostic tests based on our knowledge of safety, effectiveness, and costs.

Where do we start? In the case of the patient with cardiac problems in my office, I phoned a cardiologist with whom I have talked many times and whom I respect. I know many cardiologists who would tell me to get the nuclear stress test (one even suggested sending the patient right to the cath lab). But I have found a colleague in cardiology who knows the costs of the tests and who takes the time to think things through and talk with me. In this case, I requested the stress echo; the results were normal and the patient didn’t need further testing. The worst-case scenario would have been a need to add the nuclear stress test to the stress echo.

When it comes to ordering imaging tests, we have an abundance of choices. Over the years, I have come to know the local radiologists well, and often call one of them to ask about the best test to order for a specific patient. These conversations often lead to fewer tests and less expensive tests being ordered. I often rely on my neurology colleagues (both NPs and physicians) to advise me regarding which test would be most helpful in a given case if I’m not sure. Using a stepwise approach is also helpful; I order tests sequentially if a situation isn’t urgent. If one test isn’t diagnostic, I add another test instead of ordering a battery of tests and finding out that many of them weren’t necessary because one of them was immediately diagnostic. We NPs can make changes that will benefit individual patients and society as a whole. Questions that arise in each case don’t always have black-and-white answers. Our knowledge, experience, and clinical judgment (and our patients’ desires) will help us choose what we think is best in each case. We must remember that the most important tools we have are our hands, our ears, and our minds.

These tools will give us more information than any technology can provide. When it comes to diagnostic testing, more isn’t necessarily better. As we use all available resources—expanding our knowledge about the costs and risks of various diagnostic studies, asking colleagues for advice about which tests to order, and involving our patients in the decision-making process—we will contribute to more efficient and effective health care for our patients while being leaders in the process of healthcare reform.

Tom Bartol can be reached at .(JavaScript must be enabled to view this email address)