Breaking the guidelines: how financial unawareness fuels guideline deviations and inefficient DVT diagnostics.

Objectives: To examine factors impacting diagnostic evaluation of suspected deep vein thrombosis (DVT) by analyzing the test ordering patterns and provider decision-making within a universal health coverage system in Hungary.

Methods: We analyzed test orders for suspected DVT between 2007 and 2020, and the financial framework influencing diagnostic practices. An anonymous survey was also conducted among Emergency Department physicians to explore factors influencing diagnostic decision-making.

Results: A total of 6,821 patients were identified. From 2008 to 2013, the most common diagnostic approach combined D-dimer and duplex ultrasound tests (64.5 %), followed by sole ultrasound (20.5 %) and sole D-dimer (15 %) testing. A marked shift occurred from 2014 onward, with sole ultrasound rising to 88 % of cases by 2018-2020, while combined testing and sole D-dimer orders decreased to 7.9 and 4 %, respectively. In survey results, time efficiency emerged as a key factor for bypassing D-dimer testing, cited by 75 % of physicians. 45 % believed D-dimer costs were comparable to or higher than duplex ultrasound. Financial analysis revealed that the outdated performance points system misrepresented actual costs, resulting in duplex ultrasound being significantly underfunded, which impacts the Radiology Department. This discrepancy contributes to higher national level expenses, driven by the increased reliance on ultrasound.

Conclusions: We found diagnostic practices deviating from international diagnostic guidelines, with an increase in duplex ultrasound over D-dimer. This shift, allowed by an outdated financing structure, increases overall costs for the healthcare system. Revising financial frameworks to reflect true costs is essential for sustainable operations in universal health coverage systems.