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Subject: qotd: Are physicians driven by profits or fear?
Date: Wed, 12 Jun 2013 12:04:37 -0700
From: Don McCanne <firstname.lastname@example.org>
To: Quote-of-the-Day <email@example.com>
JAMA Internal Medicine
June 10, 2013
Appropriate Use of Myocardial Perfusion Imaging in a Veteran Population
Profit Motives and Professional Liability Concerns
By David E. Winchester, MD, MS; Ryan Meral, BA; Scott Ryals, MD; Rebecca
J. Beyth, MD, MSc; Leslee J. Shaw, PhD
Myocardial perfusion imaging (MPI) is performed millions of times
annually in the United States to assess patients for coronary ischemia.
Some have expressed concern that MPI is being used inappropriately,
possibly because of self-referral profit motives and professional
liability fears. To inform clinicians about situations in which patients
are likely to benefit from MPI testing, appropriate use criteria (AUCs)
for MPI were developed, last revised in 2009. Prior investigations have
applied AUCs to describe the magnitude and patterns of inappropriate
testing. Rates of inappropriate testing have ranged from 7% to 24%. We
hypothesized that the single-payer environment of the Veterans Affairs
(VA) health system, which eliminates self-referral profit motive and
limits liability concern, will result in less inappropriate use of MPI.
For all but 4 patients (1%), an indication from the 2009 AUCs could be
identified. Study indications were 78% (n = 259) appropriate, 13% (n =
42) inappropriate, and 8% (n = 27) uncertain. The most common
inappropriate MPI indications included testing of patients with low
pretest probability who could have undergone treadmill electrocardiogram
testing (7 patients [16.7% of total inappropriate MPI]) and asymptomatic
patients with low coronary heart disease risk (7 patients [16.7% of
total inappropriate MPI]).
In this retrospective cross-sectional investigation regarding the
appropriate use of MPI in a VA health care setting, we observed that a
substantial portion of MPI tests were ordered for inappropriate
indications. The findings are in contrast to our initial hypothesis but
are similar to those of another VA-based investigation, the results of
which were published during our investigation.
Our hypothesis was based on unique characteristics of the VA patient
care environment. First, no self-referral or profit motives exist.
Second, whereas the Federal Tort Claims Act permits medical malpractice
lawsuits against federally employed physicians, the substantial majority
of claims are resolved through administrative processes.
We did not detect a significant reduction in inappropriate testing in
the VA environment, which suggests a lesser role of defensive medicine
and self-referral in the inappropriate use of MPI.
Reasons for the observed patterns of ordering MPI are unclear.
Conceivably, commonalities in medical training, independent of
postgraduate practice environment, could contribute to an exaggerated
perception of benefit of MPI in asymptomatic patients and those at low
risk of coronary heart disease.
Comment: This study has two important lessons for health reform
advocates - one obvious and the other not so obvious.
The obvious lesson is that "excessive" medical interventions occur even
in the absence of greed or fear. In this study, since VA physicians
receive no additional income with an increased volume of services - in
this case the ordering of myocardial perfusion imaging - the tests that
were inappropriate were not done to increase personal income. Also,
since most VA malpractice claims are resolved administratively, there is
a much lower fear factor that would cause physicians to order tests to
reduce the risk of liability lawsuits.
This is good news in the respect that we can dismiss any nefarious
motives on the part of most physicians who are recommending
interventions that seem to be excessive. Policy corrections should be
directed instead to the more important causes of excessive medical
This leads to the more subtle lesson of this study. What retrospectively
is considered to be inappropriate medical management was done by
physicians who, at the time, thought that they were doing the right
thing for the patient. The policy recommendation that should follow is
that we should continue to identify best practices and continue to
educate our health professionals on just what those best practices are.
We are already doing this in the form of medical research and continuing
medical education. The process can be enhanced by greater reliance on
organizations such NICE, Cochrane, and several others. If we want to
reduce unnecessary care, our resources should be directed to these
efforts rather than being wasted on administrative excesses such as
accountable care organizations that rely on feeble measurements that are
used to distribute nominal rewards and punishments - not really much of
a motivator but more of an insult for dedicated physicians.
Physicians appreciate receiving good information and will use that in
their practices. Let's make better use our public agencies, such as the
NIH, that are dedicated to the health of patients, rather than private
agencies that jerk our health care dollars around to conform to their
Single payer really would shift the motive from "money first" to
"patients and their health first."