Docs with greater clinical knowledge less likely to order low-value imaging

Physicians with greater clinical knowledge are less likely to order low-value imaging and other unnecessary healthcare services, according to new research published Monday. 

These wasteful tests and treatments—such as imaging for an uncomplicated headache, which provides no benefit to the patient—continue plague the U.S. healthcare system. Each year, the country spends an estimated $100 billion on low-value services, experts write in JAMA Internal Medicine. 

Researchers recently aimed to better understand how higher physician knowledge might help to curb healthcare waste.  They utilized the American Board of Internal Medicine’s Longitudinal Knowledge Assessment to measure clinician know-how, matching it against IM’s ordering of 25 different low-value services including medical imaging. 

Lead author Jonathan L. Vandergrift, MS, and colleagues found a clear connection, with high-knowledge docs less likely to order unnecessary scans. 

“These findings suggest an important question for further study: If those who scored lower in the first year increase their knowledge, and therefore their score, over time, will they then order fewer low-value services?” Vandergrift, a senior health services researcher at the ABIM, said in a news announcement July 13. “We hope to learn more about whether the healthcare system may cut unnecessary costs through education and assessments that steer clinicians toward higher-value care that provides the most benefit to patients.”

The study included nearly 7,100 outpatient general internists caring for almost 900,000 fee-for-service Medicare beneficiaries in 2022 or 2023. Vandergrift and co-authors assessed docs during their first year of enrollment in the ABIM’s Longitudinal Knowledge Assessment, which uses a five-year cycle, having participants answer questions and receive regular feedback on performance. Low-value services assessed included colorectal cancer screening among patients over 85, CT for uncomplicated rhinosinusitis, MRI for rheumatoid arthritis, and imaging for syncope, plantar fasciitis diagnosis or nonspecific lower back pain.

Patients cared for by physicians in the top-performing quartile were nearly 8% less likely to receive any of the 25 low-value services compared to docs in the bottom quartile (28.6% vs. 31%). Vandergrift and co-authors also highlighted a 16% lower likelihood of patients receiving unnecessary diagnostic/preventive testing when treated by high performers (8.7% vs. 10.4%). The odds also were about 4% lower for imaging (13.2% vs. 13.8%) and 11% lower for unnecessary cancer screenings (12.3% vs. 13.8%). 

ABIM noted that about 92,000 physicians currently participate in the Longitudinal Knowledge Assessment. The testing pathway first launched in 2022 and is available to most ABIM-certified physicians along with the option to take a one-day, proctored exam in a testing center. Those who participate receive 30 questions every quarter, with explanations and journal citations provided after each question. 

The study could potentially be perceived as biased, with 3 of the 4 authors working for ABIM and the fourth receiving consulting fees from the board for his research assistance. Nevertheless, the ABIM believes the results have important implications. 

“This is an extremely rigorous analysis of the association between physicians’ clinical knowledge and judgment as measured by a standardized exam, and an outcome that is important to both patients and healthcare systems,” senior author Bradley Gray, PhD, ABIM’s Principal Health Services Researcher, said in the announcement. “Though health systems, policymakers, insurers and individual physicians all play a role in trimming costs of care, we are encouraged to see that physician expertise may be a powerful lever in helping reduce the use of unnecessary and often costly tests and treatments.”

Read more, including potential study limitations, in JAMA Internal Medicine.