Ear, Nose and Throat Docs Weigh In On Controversial Test

Doctors raise questions about the appropriate use of a nasal scope

Last week, WBUR’s Martha Bebinger wrote a story about doctors at Beth Israel Deaconess Medical Center who, for the first time, got access to a list of prices for common tests and procedures. The piece triggered a minor uprising among some ENT specialists, who offered impassioned comments on the story. Martha explains the controversy:

One primary care doctor, David Ives, the medical director of Affiliated Physicians Group, the largest group of private doctors that admits patients to Beth Israel, reacted to the price of a nasal endoscopy and said he thinks the procedure is used too often when a physical exam would suffice.

This comment angered many Ear, Nose and Throat specialists who say the development and use of this scope is one of the most important diagnostic tools in their field in recent history. Before filing the story, I searched for medical literature comparing either the cost effectiveness or the outcomes of a nasal endoscopy vs. a physical exam. I didn’t find anything. I did not call a representative of the American Academy of Otolaryngology for their views on nasal endoscopy. We offer that now.

Wendy Stern is the chair elect of the Public Relations committee for the American Academy of Otolaryngology/Head and Neck Surgery, a former president of the Massachusetts Society of Otolaryngology. Dr. Stern says nasal endoscopy allows the physician to look for signs of bacterial infection, structural changes, polyps or tumors that would not be visible without this tool.

Not using it, “could be harmful or even deadly in the event a patient had cancer,” says Stern. Using the scope appropriately “often helps reduce the need for antibiotics or other unnecessary medication,” continues Stern and can “reduce overall medical costs and the costs of sick days and time out of work.”

Stern says, as with any test, there are some doctors who perform unnecessary nasal endoscopies. But she says, “we share concerns about cost and do not condone unnecessary spending. That is why our specialty has and continues to produce evidence-based guidelines.” The academy’s guidelines for treating adults with inflamed sinuses, for example, do not recommend a scope unless there are complications that warrant the test. Stern says she scopes less than 10% of her patients.

Overuse of medical tests is a big topic as Massachusetts and other states look for ways to trim health care spending. Stern and other ENTs who commented on the story say nasal endoscopy is cost effective. I can’t add anything to these claims, or to those of primary care doctors who say the cost of the test is out of line with the benefits because no one makes the cost of the test public. I did, as I said, look for studies that show how many nasal endoscopies result in a finding that made their use worthwhile but I couldn’t fine any.

So I got in touch with Steven Pearson, President of the Institute for Clinical and Economic Review, which is part of the Institute for Technology Assessment at Massachusetts General Hospital. Here are Pearson’s thoughts on this story and controversy:

“PCPs have long known that some specialists like to do lots of tests and treatments, and others are more conservative. When there isn’t great evidence to guide practice, we will always see variation in the use of procedures based on the varying skills, experiences, reimbursement status, and mindsets of different specialists. A good PCP knows his or her specialists well, and should take into consideration whether the specialist is a good diagnostician and does not indiscriminately use invasive and expensive technologies.”

In talking to Drs. Stern, Pearson (as well as a dozen ENTs and primary care doctors about this story), there may be common ground and it may sound something like this:

Nasal endoscopy is an important test that is cost effective when used appropriately. But as long as doctors are worried about lawsuits and are paid based on how often they do a test, there will be some inappropriate use.

Sound right?

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  • Roger

    “Nasal endoscopy is an important test that is cost effective when used appropriately. But as long as doctors are worried about lawsuits and are paid based on how often they do a test, there will be some inappropriate use.”
    You left out the key phrase, “so long as there isn’t great evidence to guide practice” —there will be some inappropriate use.  I think that is the critical issue here.  I find it interesting that this gets lost in the discussion so often. 

    I fear that the meme: “fee for service payments lead to inappropriate use” has taken hold despite the total lack of evidence to back it up.   I am certain that systems with big fat global payment contracts use nasal endoscopy just as frequently or more often than systems “paid based on how often they do a test.”   By the way, even under global payment contracts, all private specialists are– and always will be– paid by how often they do a test.  There’s no other way to do it unless you employ all of your physicians and we do away with private practice models.  Regardless, no matter which way– employed or private– they still won’t have great evidence to guide their practices.  Isn’t that the real issue?