This is What I'm Talking About When I Argue for Efficient Care Incentives

Insuring Resources Commentary:

We need to improve the efficiency of care and provide doctors inentives to try less invasive and less costly tests first. The article suggests: To decide whether someone needs an angiogram, a doctor assesses a patient's medical status and symptoms, and usually tries a noninvasive test, such as an ultrasound of the heart or having the patient run on a treadmill. It is this gatekeeper process that needs improvement, researchers suggested in Thursday's issue of the New England Journal of Medicine.

The current health care reform proposals do nothing to combat this problem.

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Study Suggests Too Many Invasive Heart Tests GivenAssociated Press
Malcolm Ritter
March 10, 2010


A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.

The researchers said the findings suggest doctors must do better in determining which patients should be subjected to the cost and risks of an angiogram. The test carries a small but real risk - less than 1 percent - of causing a stroke or heart attack, and also entails radiation exposure.

"We can do better. There is no doubt in my mind," said Dr. Ralph Brindis of the University of California, San Francisco, one of the study's authors.

Every year in the United States, more than a million people get an angiogram, in which a thin tube is inserted in the arm or groin and threaded up to the heart to check for blocked arteries that could lead to a heart attack. Dye is injected through the tube to make blockages show up on X-rays.

Angiograms are often given to patients who might be having a heart attack or have symptoms that suggest a serious blockage. They are also sometimes done on people who may have some less clear-cut symptoms, like shortness of breath, or no symptoms but some risky traits like high cholesterol and an abnormal result on another heart test. This group accounts for about 20 to 30 percent of angiogram cases.

In the study, nearly two-thirds of the patients in this second group were found to have no serious blockages.

The researchers could not establish why so few proved to have heart disease. But Dr. Harlan Krumholz, a Yale cardiologist and health-outcomes researcher unconnected to the study, said he thinks the problem arises because doctors are afraid of missing something, and also getting sued.

"We fear doing too little," he said. "I think that we developed a culture where people feel that doing more and knowing more is always the proper course. What that does is sometimes lead us to overuse."

To decide whether someone needs an angiogram, a doctor assesses a patient's medical status and symptoms, and usually tries a noninvasive test, such as an ultrasound of the heart or having the patient run on a treadmill. It is this gatekeeper process that needs improvement, researchers suggested in Thursday's issue of the New England Journal of Medicine.