Physicians ordering low-value screening tests: What can be done?

Primary care physicians who order a large number of one low-value screening test tend to order large numbers of other low-value screening tests as well, according to a new study published in JAMA Network Open. The authors suggested that high-intensity interventions focused on these physicians may be one way to reduce such low-value care going forward.

“The Choosing Wisely (CW) campaign, present in more than 20 countries worldwide, is dedicated to reducing the frequency of low-value care, which represents little to no patient benefit or comparatively greater risk of harm,” wrote Zachary Bouck, MPH, of the Institute for Health Systems Solutions and Virtual Care at Women’s College Hospital in Toronto, Ontario, Canada, and colleagues. “While the CW campaign has been successful at identifying what constitutes low-value care and raising awareness among members of the medical community and general public, the results of the campaign on reducing low-value care outside of focused local efforts have been underwhelming.”

To take aim at low-value care, the authors studied healthcare claims data from Ontario from April 1, 2012, to March 31, 2016. Orders placed for four low-value screening tests were examined: repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Pap tests and chest radiographs (CXRs).

Overall, looking at a cohort of more than 2,000 primary care physicians, the authors found that more than 302,000 low-value screening tests were ordered. This included more than 74,000 DXA scans, more than 179,000 ECGs, more than 19,000 Pap tests and more than 28,000 CXRs. “Frequent users”—18.4 percent of the physicians who ordered 39.2 percent of the exams—were determined.

“Physicians who were male, further removed from medical school, or in an enhanced fee-for-service payment model (family health group) versus a capitated payment model (family health team) had increased odds of being generalized frequent users,” the authors wrote.

So what can be done to get these physicians to dial back their utilization of these low-value screening tests? Bouck and colleagues shared one suggestion that could help educate providers across the board.

“Our data suggest that future interventions should consider a more focused, intensive approach on the minority of physicians who frequently order low-value care,” the authors concluded. “One could imagine a higher-intensity intervention aimed at the minority of high-ordering physicians (eg, academic detailing) and a lower-intensity intervention (eg, broad awareness and education campaigns) aimed at physicians who order low-value care infrequently. Such an approach would avoid exposing physicians who infrequently order low-value care to potentially burdensome quality improvement initiatives for which the marginal benefit may be limited and may be more cost-effective.”