College workgroup compiles list of unnecessary tests
A workgroup of internists convened by ACP has developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.
The list was developed by a consensus-based process and published in the Jan. 17 Annals of Internal Medicine, with a goal of promoting thoughtful discussions about which tests and interventions promote high-value, cost-conscious care. The list includes a variety of inpatient and outpatient situations in which the experts felt use of a test may provide no benefit or be harmful, including cardiac tests, cancer screens and monitoring practices. Situations on the list particularly likely to be encountered by hospitalists include:
- Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure
- Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery
- Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features
- Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism
- Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation-perfusion scintigraphy) in patients with intermediate or high probability of venous thromboembolism
- Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology
- Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery and
- Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding.
The workgroup also suggested some general principles for providing high-value care in testing. First, diagnostic tests usually should not be performed if results will not change management. Second, in situations where the pre-test probability of disease is low, the likelihood of a false-positive could be higher than the likelihood of a true-positive, potentially leading to expensive and harmful further testing. Finally, when considering the cost of a test, downstream costs, such as follow-up testing, should be considered, the group said.
An editorial accompanying the article noted that some physicians will likely take issue with some of the items on the list. The editorial also suggested a number of questions that physicians should ask themselves in order to determine whether a test will provide high value, including whether the test results are available from another source, what effects giving or not giving the test are likely to have, and whether the test is being ordered primarily to reassure the patient.
Chlorhexidine sponges save money in the intensive care unit
Use of chlorhexidine-impregnated sponges for central venous and arterial catheters saves hospitals money by preventing infections, according to a recent cost analysis.
A previously reported study of 1,636 patients and 28,931 catheter-days in seven French ICUs found that use of chlorhexidine-impregnated sponges decreased incidence of major catheter-related infections to 0.6 from 1.4 per 1,000 catheter-related days, and that scheduled dressing changes every seven days weren't inferior to changes every three days. The current evaluation sought to assess the cost benefits of using the sponges on both an every-seven- and every-three-days dressing change regimen. Researchers measured the direct costs of the sponges, treating contact dermatitis caused by the sponges, diagnosing catheter colonization, treating catheter-related infections, and additional length of stay (LOS) related to major catheter-related infections. They estimated costs for LOS by assuming a cost of $2,118 per intensive care unit day. Results were published in the January Critical Care Medicine.
The overall cost of a major catheter-related infection was $24,090 per episode. Each dressing cost $9.08 and each chlorhexidine-impregnated sponge cost $9.73. The estimated extra length of stay due to an infection was 11 days. When compared to the reference standard (use of regular dressings changed every three days), use of chlorhexidine sponges every three days saved $197 per catheter, use of chlorhexidine sponges every seven days saved $133 per catheter, and use of regular dressings every seven days saved $50 per catheter. With the three-day dressing strategy, chlorhexidine sponges were cost-saving when the baseline major catheter-related infection rate was higher than 0.141%, while with the seven-day strategy, they were cost-saving when the rate was higher than 0.212%.
Study limitations include that the mean cost per ICU day of $2,118 may have been an underestimation, since costs of imaging studies or procedures during the ICU stay weren't counted, the authors wrote. Use of chlorhexidine sponges requires specific training of health care workers, the cost of which wasn't taken into account, they added. Still, while 2010 Centers for Disease Control and Prevention recommendations support use of chlorhexidine sponges when catheter-infection rates are high, this analysis suggests use of these sponges reduces costs even when the baseline infection rate is low, the authors wrote.