Low-value testing—including imaging—balloons downstream utilization and may cost healthcare billions
Primary care patients who undergo low-value screening exams, such as chest radiography, as part of their annual health visits are more likely to experience downstream diagnostic testing and specialist appointments compared to those who do not. These services often do not improve outcomes and can cost the U.S. healthcare system billions.
That’s what a team of Canadian and U.S. researchers found after studying chest radiograph, electrocardiogram and Papanicolaou testing performed in hundreds of thousands of low-risk, primary care outpatients in Canada.
The analysis, published June 9 in JAMA Internal Medicine, revealed that these low-value tests may actually expose individuals to more harm than good and can cost the system up to $101 billion annually, according to one estimate cited in the study.
“The results of the present 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,” wrote Zachary Bouck, MPH, with Women’s College Hospital, in Toronto, Ontario, and colleagues. “Therefore, in discussing the risks and benefits of screening tests with low-risk patients, physicians should help patients weigh the potential for harm against uncertain benefit.”
For their study, Bouck and colleagues looked at population-based administrative healthcare claims from primary care outpatients who underwent an annual health exam between April 2012 and March 2016. For each of the three tests, they defined low-value screening as chest radiography within a week of a patient’s visit; a Papanicolaou test within seven days; and an ECG within 30 days.
Looking at the 43,532 low-risk patients in the chest radiography group, at 90 days this cohort was associated with an additional 0.87 and 1.96 patients having an outpatient pulmonology visit or an abdominal or thoracic CT scan per 100 patients, respectively.
A similar trend was found among the 245,686 patients included in the ECG group. Low-risk individuals were linked to an extra 1.92, 5.49, and 4.46 patients receiving an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively.
Nearly 300,000 women were included in the Papanicolaou testing group. And at 180 days, these patients were associated with an added 1.31 and 0.84 patients undergoing an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively.
The total amount of “clinical events” after one year was low, the authors noted, due to the good health of patients in their study. And while those who had chest imaging and ECGs experienced slightly higher procedure-related risks, they experienced no meaningful reduction in one-year mortality risk.
Bouck added that the data used in this study did not include every indication to confirm why the tests were ordered, meaning some people could have undergone a chest scan or ECG for undocumented reasons rather than screening. Despite this, their research remains valuable, they said.
“To our knowledge, this work is the largest cohort study to demonstrate the association of low-value screening tests with downstream healthcare use, or care cascades, in primary care,” the authors concluded.
Matt joined Chicago’s TriMed team in 2018 covering all areas of health imaging after two years reporting on the hospital field. He holds a bachelor’s in English from UIC, and enjoys a good cup of coffee and an interesting documentary.