ACP workgroup compiles list of low-value 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 was 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 several cardiac tests, cancer screens and diagnostic studies.
Some situations in which the workgroup unanimously concluded that a test does not reflect high-value care include:

• obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults,
• screening for colorectal cancer in adults older than 75 years or in adults with a life expectancy of less than 10 years,
• performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology,
• performing imaging studies in patients with nonspecific low back pain,
• performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination, and
• 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.

The workgroup also suggested some general principles for providing high-value care with testing. First, diagnostic tests usually should not be performed if the 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 and invited all readers of the article to take a brief Web survey to indicate their agreement or disagreement. The editorial also suggested a number of questions that physicians should ask themselves to determine whether a test will provide 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.