When Done Correctly, the History and Physical Can Save Money
A recent commentary demonstrated that the role of the history and physical examination in achieving correct diagnoses has not been supplanted by the contemporary proliferation of tests and imaging.1 Well, it did not take long for like-minded studies to drive that truism home with emphasis. Let’s look at a disease with a hefty and increasing prevalence, peripheral neuropathy.
ROLE OF THE HISTORY AND PHYSICAL IN PERIPHERAL NEUROPATHY
Callaghan and coworkers2 utilized the 1996 to 2007 Health and Retirement Study Medicare Claims-linked database to identify individuals with peripheral neuropathy (n 5 1031, or 8.1% of a total cohort of 12,673 individuals). The authors observed that the prevalence of this disease is between 2% and 7% of the general population, but it can be as high as 15% among those older than age 40.
Once the diagnosis is made by the history and physical examination, there are guidelines for appropriate and yet limited initial workup.3 What should be ordered? Fasting glucose, a vitamin B12 level, serum protein electrophoresis, and a 2-hour glucose tolerance test (or “GTT” if necessary after a fasting glucose measurement). Seems simple, doesn’t it? Sorry, it is not.
A PLETHORA OF UNNECESSARY TESTS
In the real world, there are a staggering 4001 patterns of testing! Remember our theme: a careful history and physical followed by “appropriate” testing gets the right answer a majority of times. Despite the fact that a GTT is recommended by evidence-based medicine, expensive MRI scans of the brain (remember these are peripheral neuropathies discovered on examination, not brain lesions) or spine are performed more frequently, with 23.2% of the peripheral neuropathy cohort undergoing MRI scans versus only 1.0% receiving GTTs. In fact, brain MRI scans exceeded MRI scans of the spine.
You probably have already guessed the consequence: costs for this plethora of unnecessary tests have increased Medicare expenditures.
A WAKE-UP CALL
The editorialist began his commentary with a quote from The Magic School Bus: “Well, if you don’t look, you don’t see, and what you don’t see can be very hard to find.”4 He then makes some profound observations. “A careful history and examination take time, a disappearing commodity in primary care and cognitive-based specialties. . . . It seems the threshold for MRI is often the mere presence of a primary neurologic symptom. . . . Thus the MRI is increasingly viewed as a ‘routine’ test.”4 He then says that Callaghan and colleagues’ data2 should be a wake-up call.
Readers have responded in favor of a resuscitation of the history and physical examination after the first go-round.5 Will there be more joining the clarion call after this paper and commentary?
1. Rutecki GW. Is the history and physical worth doing anymore? Consultant. 2012;52:16.
2. Callaghan B, McCammon R, Kerber K, et al. Tests and expenditures in the initial evaluation of peripheral neuropathy. Arch Intern Med. 2012;172:127-132.
3. Evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing. Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology. 2009;72:185-192.
4. Gordon Smith A. Diagnosis of neuropathy. We can (and must) do better. Arch Intern Med. 2012;172:132-133.
5. Rutecki GW. Is the history & physical still relevant? Readers respond. Consultant. 2012;52:261.