Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care.

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.

Laboratory screening at preventive health exams: trend of testing, 1978-2004.

BACKGROUND: Routine laboratory screening at preventive health exams continues to be a common practice despite expert opinion dating back to 1979 that supports only a few screening tests for apparently healthy adults. This report describes trends in such testing over a 27-year period. METHODS: Primary care physicians were surveyed five times between 1978 and 2004 at a yearly educational meeting in Colorado. Based on case vignettes describing two apparently healthy adults, physicians indicated which laboratory tests they would routinely order. RESULTS: Of a total of 2364 surveys collected during years 1978, 1983, 1988, 1999, and 2004, the corresponding percentage of physicians respondents who state they would order the following tests for a healthy man aged 35 years were: complete blood count (CBC) (87, 75, 73, 49, 46); urinalysis (UA) (93, 86, 79, 52, 44); chemistry panel (CHEM) (57, 48, 36, 43, 55); and electrocardiogram (ECG) (37, 27, 24, 9, 6). For a healthy woman aged 55 years, the corresponding percentages for each test were: CBC (89, 89, 86, 64, 67); UA (96, 93, 88, 62, 55); CHEM (70, 70, 66, 57, 76); ECG (63, 51, 51, 33, 29); and thyroid stimulating hormone (14, 20, 28, 42, 57). CONCLUSIONS: Although currently practicing physicians continue to report that they order screening tests for apparently healthy people, this practice appears to have decreased over the past 27 years. This trend may reflect expert guidelines and emphasis on medical cost containment.

Effect of a mailed brochure on appointment-keeping for screening colonoscopy: a randomized trial.

BACKGROUND: Even when primary care physicians have face-to-face discussions with patients before referring them for screening colonoscopy, patient nonadherence can be substantial. Often, primary care physicians lack sufficient time to educate patients and address their potential misconceptions and fears about this procedure. OBJECTIVE: To test whether an informational brochure sent to patients' home addresses after referral for screening colonoscopy would increase patient completion of the procedure. DESIGN: Randomized, controlled trial. SETTING: 2 general internal medicine practices affiliated with the University of Colorado Health Sciences Center. PATIENTS: 781 consecutive patients 50 years of age or older referred by their primary care physicians for screening colonoscopy. INTERVENTION: Patients were randomly assigned to receive usual care (control group) versus usual care plus an informational brochure (intervention group). The brochure was mailed within 10 days of referral for screening colonoscopy; it mentioned the name of the patient's primary care physician and encouraged patients to schedule a procedure. It also described colorectal cancer and polyps and the similar lifetime risks for colorectal cancer for men and women, colonoscopy and risk for perforation, the nature of bowel preparation for the procedure, and alternative screening tests. MEASUREMENTS: Rates of adherence to screening colonoscopy in the 2 study groups. RESULTS: The overall adherence rate was 11.7 percentage points (95% CI, 5.1 to 18.4 percentage points) greater in the intervention group than in the control group (70.7% vs. 59.0%). Older patients were more adherent than younger patients. Patients with low-income insurance plans, such as Medicaid, were less adherent despite being sent a brochure. LIMITATIONS: The small number of clinical practices and minority patients may limit generalizability. In addition, it was not possible to determine the degree to which adherence was influenced by a reminder to schedule a procedure versus detailed information about colonoscopy. CONCLUSIONS: An inexpensive mailed brochure is an effective way to increase patient adherence to primary care physician referral for screening colonoscopy.