Low-value testing of low-risk patients increases downstream testing and procedures

Low-value testing — testing that may not improve patient outcomes – of low-risk patients during annual check-ups is likely to increase subsequent specialist visits, diagnostic tests, and procedures, researchers found.

Specifically, they found that patients who receive a chest radiograph, electrocardiogram, or Papanicolaou (Pap) test on the date of, or shortly after, their annual health exam are at an increased risk of subsequent specialist visits, diagnostic tests, and procedures in the following 90 and 180 days

The population-based retrospective cohort study, led by Zachary Bouck, MPH, Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, was published in JAMA Internal Medicine.

Bouck and colleagues pointed out that despite recommendations from campaigns such as Choosing Wisely aimed at reducing the frequency of low-value healthcare services, there has not been any large-scale change in these testing practices. And, according to the authors, the financial burden of this low-value testing on the U.S. healthcare system is substantial, ranging from $75 billion to $101 billion annually.

They also noted that in addition to the costs associated with these tests, abnormal results will often lead to a “care cascades” in the form of subsequent testing and treatments that expose patients to harms from healthcare interventions that are potentially unnecessary.

In this study, the authors assessed the association of three low-value screening tests — chest radiograph, electrocardiogram, and Pap test — with downstream healthcare use and clinical outcomes in healthy patients undergoing annual health exams.

The study used administrative health care claims from Ontario, Canada, for patients undergoing check-ups between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into three groups — adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease (chest radiograph cohort), adult patients at low risk for cardiovascular disease (electrocardiogram cohort), and female patients (age 13-20 years or older than 69 years) at low risk for cervical cancer (Papanicolaou test cohort).

Patients in these groups were followed up to see whether they had the corresponding low-value screening test on the date of or shortly after their health exam. The main outcomes of the study were specialist visits, diagnostic tests, and procedures within 90 days after a low-value test, or the end of the exposure observation window in the case of patients who were not tested

Bouck and colleagues found that in low-risk patients:

  • Chest radiographs (at 90 days) were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic CT scan per 100 patients, respectively.
  • Electrocardiograms (at 90 days) were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively.
  • Papanicolaou testing (at 180 days) was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively.

The authors concluded that the results of their study “support the premise that seemingly low-risk screening tests may lead to physician visits or tests that could inconvenience the patient and, in some instances, expose the patient to potential harm.”

In a commentary accompanying the study, Timothy S. Anderson, MD, MAS, Beth Israel Deaconess Medical Center, Boston, Massachusetts, and Grace A. Lin, MD, MAS, University of California, San Francisco, observed that for many patients and physicians there are few incentives to reduce testing simply to cut healthcare costs.

“Efforts to reduce low-value testing through emphasis solely on cost savings are unlikely to be prioritized by fee-for-service health systems or physicians who may stand to lose revenue or by patients who may perceive these efforts as rationing,” they wrote, adding that efforts to reduce low-value testing will have to require an understanding of the negative consequences of these tests, beyond the costs involved.

While the study by Bouck and colleagues provide real world evidence concerning the downstream effects of the low-value testing, Anderson and Lin argued that more specificity will be needed to inform efforts to successfully “deimplement” low-value tests.

“Successful deimplementation efforts will require an improved understanding of drivers of testing and comparison of interventions targeting patients, clinicians, and reimbursement policies,” they wrote.

  1. Low-value tests in low-risk patients result in increased downstream testing and procedures.

  2. Patients who receive a chest radiograph, electrocardiogram, or Papanicolaou test on the date of or shortly after their annual health exam are at increased risk of subsequent specialist visits, diagnostic tests, and procedures.

Michael Bassett, Contributing Writer, BreakingMED™

Anderson reported receiving grants from the National Institute on Aging and the American College of Cardiology.

Lin reported receiving grants from the National Cancer Institute, the Mt Zion Health Fund, the National Heart, Lung, and Blood Institute, and the Tobacco-Related Diseases Research Program and receiving contract work from the Institute for Clinical and Economic Review.

Cat ID: 192

Topic ID: 86,192,730,192,925