Payers, providers, and patients recognize that unnecessary and overused medical tests and treatments drive up healthcare costs substantially, to the tune of nearly $7 billion, according to one study published in the Archives of Internal Medicine. Such recognition has resulted in initiatives, such as the Choosing Wisely campaign, as well as a shift by the Centers for Medicare & Medicaid Services (CMS) to link reimbursement to the quality and value of the care provided rather than volume.
Despite recognition that more care is not necessarily better care, a study published in the April 16, 2015, issue of the New England Journal of Medicine shows that when it comes to cataract surgery, providers continue to order preoperative testing for Medicare patients, even when it’s not needed. Although guidelines advocate the elimination of medical tests such as chest radiographs, blood tests, and electrocardiograms in patients with no risk factors, physician practice patterns apparently are difficult to change. According to Dr. Catherine Chen, the lead author of the study, about half of the ophthalmologists who performed cataract surgery on Medicare patients in 2011 ordered unnecessary tests, the same percentage as in 1995.
So why don’t physicians adhere to best practices? Several reasons have been proposed, including a lack of awareness of clinical guidelines, a perception that preoperative testing will improve surgical outcomes, and an assumption that such test results may be needed downstream by another surgeon or anesthesiologist. Defensive medicine and patient expectations likely also play a role.
Interestingly, the American Academy of Ophthalmology hopped aboard the Choosing Wisely campaign in February 2013, when it released a list of 5 things physicians and patients should question. At the top of the list: Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.
Unfortunately, lack of guideline adherence isn’t limited to ophthalmology. In all specialties, a gap exists with regard to the adoption and implementation of evidence-based approaches to care. Clearly, more work needs to be done to reduce disparities and variations in care, promote use of effective and high-value services, and ensure smarter spending of our healthcare dollars.