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Patient Safety Tip
of the Week
May
18, 2021
Medical
Overuse Is Not Just An Economic Problem
We
often do presentations on what’s wrong with our
current healthcare system. Two significant factors we highlight are unnecessary
testing and low-value care. The economic consequences of the “diagnostic
cascade” are well known and frequently reported on. But that diagnostic cascade
can also result in patient harm, particularly when it ultimately leads to a
low-value procedure or other intervention.
Fisher
and Welch (Fisher 1999) developed a schematic showing the
mechanisms by which more medical care can lead to harm. More diagnosis
creates the potential for labeling and detection of pseudodisease—disease
that would never become apparent to patients during their lifetime without
testing. More treatment may lead to tampering, interventions to correct
random rather than systematic variation, and lower treatment thresholds, where
the risks outweigh the potential benefits. Because there are more diagnoses to
treat and more treatments to provide, physicians may be more likely to make
mistakes and to be distracted from the issues of greatest concern to their
patients.
Korenstein et al. (Korenstein
2018) developed a conceptual map that documents
that overused tests and treatments and resultant downstream services generate 6
domains of negative consequences for patients:
- Physical
- Psychological
- Social
- Financial
- Treatment burden
- Dissatisfaction with health care
They note that negative consequences can result from
overused services or from downstream services. They can also trigger further
downstream services that in turn can lead to more negative consequences, in an
ongoing feedback loop. One example they provide is a screening colonoscopy in
an 80-year-old man leading to a biopsy, hospitalization, and follow-up imaging
tests and, perhaps, even a bowel perforation during a colonoscopy which may, in
turn, lead to chronic gastrointestinal symptoms. Another was an unnecessary
screening low-dose computed tomography (LDCT) scan which
revealed scattered nodules. This finding led to a 3-month follow-up scan, which
then led to a positron emission tomography (PET) scan, a surgical evaluation,
and ultimately another follow-up scan. Another was unnecessary CT angiography showing
coronary artery disease, which led to coronary angiography and ultimate 3-vessel
CABG, with heart failure as a complication of the CABG.
Their
review of cases in the literature found 54 case descriptions with a total of 63
overused services. Nearly all case descriptions (91%) described the overuse
cascade, with a mean of 4.2 downstream services identified per case and 227
downstream services mentioned in total. Physical harms predominated (69%),
followed by psychological consequences (16%) and treatment burden (9%),
financial consequences (3%), dissatisfaction with health care (2%), and social
consequences (1%). The authors do acknowledge that the high frequency of cases
reporting physical harm may result from publication bias.
Over
the last decade, the Choosing
Wisely
campaign has compiled lists from national organizations representing medical
specialists to identify tests or procedures commonly used in their field whose
necessity should be questioned and discussed. Many examples of what is referred
to as “low-value” care have come from such lists. In addition, the JAMA Internal
Medicine “Less is More” series has provided multiple examples of
low-value care leading to unwanted consequences.
There
has been a spate of articles recently about low-value care and unnecessary
testing.
One classic example deals with cataract surgery. One of the
American Academy of Ophthalmology’s Choosing Wisely items is “Don’t perform preoperative medical tests
for eye surgery unless there are specific medical indications.” That statement
notes that, for many, preoperative tests are not necessary because eye
surgeries are not lengthy and don’t pose serious
risks. It further states that an EKG should be ordered if patients have heart
disease and, in general, patients scheduled for surgery do not need medical
tests unless the history or physical examination indicate the need for a test,
e.g., the existence of conditions noted above. Institutional policies should
consider these issues. Yet many patients undergoing cataract surgery still get
some preoperative testing. Ganguli et al. (Ganguli
2019a) looked at preoperative
electrocardiogram (EKG) for Medicare patients undergoing cataract surgery without
known heart disease. They compared downstream testing and events in those who
got a preoperative EKG versus those that did not. Those who received a
preoperative EKG experienced between 5.11 and 10.92 additional events per 100
beneficiaries relative to the comparison group. This included between 2.18 and
7.98 tests, 0.33 treatments, 1.40 new patient cardiology visits, and 1.21 new
cardiac diagnoses. Spending for the additional services was up to $565 per
Medicare beneficiary, or an estimated $35,025,923 annually across all Medicare
beneficiaries in addition to the $3,275,712 paid for the preoperative EKG’s.
They estimated that 14.7% of preoperative EKG recipients had a potential
cascade event.
Though
Ganguli et al. were not able to determine how many of
those patients suffered harm as a result of having a preop EKG, they cited the
US Preventive Services Task Force statement (Curry 2018) that screening EKG in low-risk,
asymptomatic patients can lead to harms including “unnecessary invasive
procedures, overtreatment, and labeling”. Ganguli et al. do acknowledge that,
lacking clinical details on all patients, some may also have benefitted from
the diagnostic cascade.
Ganguli
et al. (Ganguli 2020) also assessed the prevalence of several
low-value tests (routine electrocardiograms, urinalyses, and thyrotropin tests)
during Medicare Annual Wellness Visits and how these related to cascades of
further tests or care. They found that 18.6% of patients received at least 1
low-value test including an ECG (7.2%), urinalysis (10.0%), or thyrotropin test
(8.7%) during such visits. A total of 6.1 cascade-attributable events per 100
beneficiaries occurred in the 90 days following routine ECGs and 5.4 following
urinalyses. Cascade-attributable cost per beneficiary were $9.62 for ECG’s and
$7.46 for urinalyses. No cascade-attributable events or costs were found to be
associated with thyrotropin tests.
Among
patients who received any routine test, 13.5% had a potential cascade laboratory
test, 6.6% had a potential cascade imaging test, 3.9% had a potential cascade
procedure, 8.6% had a potential cascade visit, 2.0% had a potential cascade new
diagnosis, and 0.3% had a potential cascade hospitalization. Again, lacking
clinical details, it is unknown whether some patients were harmed as a result
of these and it is very conceivable that some patients
benefited.
Similarly,
Bouck et al. (Bouck 2020) looked at low-value testing with subsequent
care among low-risk primary care outpatients undergoing an annual health
examination (AHE) in Ontario, Canada. Specifically, they identified patients
who received 1 of 3 tests identified by Choosing Wisely Canada as low value in low-risk
populations: chest radiographs, electrocardiograms (ECG’s), and Papanicolaou
tests. At 90 days, patients receiving any of these tests were more likely to
see specialists and more likely to undergo both additional noninvasive and
invasive testing or procedures compared to patients who did and did not receive
an initial low-value test.
We discussed the issue of incidental findings in our
April 13, 2021 Patient Safety Tip of the Week “Incidental
Findings – What’s Your Strategy?”.
While our focus was on avoiding “falling through the cracks”, it is important
to recognize the cascade effect that results from incidental findings on lab or
imaging studies. Once again, Ganguli and colleagues (Ganguli
2019b) have assessed the
cascade effect that follows incidental findings on screening and diagnostic
tests. In a nationally representative survey of physicians, almost all
respondents reported experiencing cascades, including cascades with clinically
important and intervenable outcomes and cascades with no such outcome.
Physicians reported cascades caused their patients psychological harm (68.4%),
physical harm (15.6%), and financial burden (57.5%) and personally caused the
physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety
(45.4%).
When
asked about their most recent cascade, 33.7% reported the test revealing the
incidental finding may not have been clinically appropriate. During that most
recent cascade, physicians reported that guidelines for follow-up testing were
not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the
negative consequences of cascades, 62.8% of respondents chose accessible
guidelines and 44.6% chose decision aids as potential solutions. We discussed
implementation of such solutions in our April 13, 2021 Patient Safety Tip of
the Week “Incidental Findings – What’s Your Strategy?”.
Chalmers et al. (Chalmers
2021) looked at low-value
services provided to Medicare patients. Head imaging for syncope was the
highest-volume low-value service (29.9%), followed by coronary artery stenting
for stable coronary disease (15.8%). They developed a composite overuse score
ranging from 0 (no overuse of services) to 1 (relatively high overuse of
services) to compare hospital performance. They found the highest scores were
associated with nonteaching and for-profit hospitals, particularly in the
South. This work was related to the Lown Institute,
which publishes a Hospital
Index that compares hospital
performance on twelve low-value services, such as hysterectomy for benign
disease, coronary stents for stable heart disease, and head imaging for
syncope.
The recent trend toward more employment of physicians by
hospitals may have had a negative impact on overuse of some services. Young et
al. (Young
2021) investigated inappropriate
ordering of MRI scans in Massachusetts for three common medical conditions:
lower back pain, knee pain, and shoulder pain. They found that the odds of a
patient receiving an inappropriate MRI referral increased by more than
20 percent after a physician transitioned to hospital employment. Most
patients who received an MRI referral by an employed physician obtained the
procedure at the hospital where the referring physician was employed. These
results point to hospital-physician integration as a potential driver of
low-value care.
Müskens et al. (Müskens 2021)
reviewed the literature on diagnostic testing overuse. They concluded that
substantial overuse of diagnostic testing is present with wide variation in
overuse. The highest prevalence of overuse was reported for: use of
electrocardiograms, chest X-rays or pulmonary function tests in low-risk
patients having low-risk surgery (97.5%); imaging for low back pain within the
first 6 weeks of symptom onset in the absence of red flags (86.2%); knee
arthroscopy for meniscal derangements (81.7%); baseline lab tests for low-risk
patients receiving low risk surgery (78.6%); and knee arthroscopy for osteoarthritis
(71.7%). Overall, imaging in case of nonspecific low back pain and preoperative
tests, such as preoperative baseline lab tests, echocardiography
or exercise stress tests, were the most often assessed diagnostic practices
identified in this study.
Low-value care includes not only examples from diagnostic
testing but also procedures and other interventions. As above, low-value
procedures often result from low-value diagnostic testing. For example,
screening an asymptomatic high-risk patient for carotid stenosis may lead to a
carotid endarterectomy. Procedures are the most likely to be associated with
patient harm or other patient safety issues. Attempts have been made to measure
harms from low-value care indirectly by measuring rates of both low value care
and hospital complications (Brownlee
2017).
But Badgery-Parker et al. (Badgery-Parker 2019)
sought a more direct measurement. They looked at the following low-value
procedures (chosen from Choosing Wisely and other sources) in a large patient
database in Australia:
- endoscopy
for dyspepsia in people younger than 55
- knee
arthroscopy for osteoarthritis or meniscal tears
- colonoscopy
for constipation in people younger than 50 years
- endovascular
repair of abdominal aortic aneurysm in asymptomatic, high-risk patients
(EVAR)
- carotid
endarterectomy in asymptomatic, high-risk patients
- renal
artery angioplasty
- spinal
fusion for uncomplicated low back pain
They
used 16 hospital-acquired complications (HAC’s) as a measure of harm associated
with low-value care.
The
percentage of low-value episodes with any HAC ranged from 0.1% for endoscopy to
15.0% for EVAR. Predictably, HAC rates were higher for those procedures done in
high-risk patients, such as carotid endarterectomy and EVAR, but high rates
were also seen for renal artery angioplasty and spinal fusion. Moreover, the
occurrence of a HAC at least doubled the hospital length of stay for each of
the 7 procedures studied.
For most procedures, the most common HAC was healthcare-associated
infection, which accounted for 26.3% of all HAC;s observed. But cardiac complications occurred relatively
frequently for carotid endarterectomy, EVAR, and renal artery angioplasty (9.7%,
5.7%, and 4.6% respectively).
And, of course, the other major area of more medical care
leading to harm has to do with medications. Sometimes it’s hard to distinguish “overuse” form “misuse”
but both can give rise to patient harm. Overuse would include inappropriate
prescribing of antibiotics for conditions not likely to require antibiotics.
Misuse would include examples like polypharmacy or prescription of potentially inappropriate
medications (PIM’s) in the elderly. Discussion of these medication-related
harms is beyond the scope of today’s column but can be found in our many
columns on medication safety.
All
this has led to calls for “deimplementation
science”. Anderson and Lin (Anderson 2020), in a commentary on the Bouck
study, called for more focused research on testing cascades and their outcomes.
They note that most studies have utilized administrative data, which lacks the
clinical details we need to better understand cause and effect, rationales, and
factors contributing to low-value testing.
So, how do we cut down on low-value care? One study showed
that Choosing Wisely had minimal impact on one example, whereas stopping
payment for the low-value service had a dramatic impact. Henderson et al. (Henderson
2020) looked at the impact of
Choosing Wisely recommendations regarding 2 low-value tests (vitamin D
screening and triiodothyronine tests). Choosing Wisely recommendations were
associated with reductions 13.8% for US Veterans Health Administration, and
14.0% for US employer-sponsored insurance. They compared that to the impact of
an Ontario, Canada payment policy change that eliminated reimbursement of
vitamin D screening. That was associated with a 92.7% relative reduction in
such screening. (There was no significant difference in the frequency of triiodothyronine
testing.)
Wolf
et al. (Wolf 2021), in a viewpoint on deimplementation
in pediatrics, offer insights into the problem of low-value care in general.
They note that, despite significant progress in the identification of low-value
services, overuse continues. And, as we’ve noted, guidelines
alone seem insufficient to change clinical practice. They describe factors at
the level of the patient (parental pressures, direct-to-consumer advertising), clinician
(fear of missing a diagnosis, malpractice suits), and health care system (fee-for-service
reimbursement, short visit times) that continue to drive overuse. Cognitive
biases such as the “endowment effect” also make clinicians less likely to end
historical practices.
One additional factor contributing to overdiagnosis and medical
overuse was recently emphasized: we regularly overestimate the probability of
disease. Morgan et al. (Morgan
2021)
surveyed practitioners and presented them with clinical scenarios and asked
them to estimate pretest probability of disease and posttest probabilities
after both positive and negative test results. Individual testing questions
pertained to mammograms for breast cancer, stress testing for cardiac ischemia,
chest radiography for pneumonia, and urine cultures for urinary tract infection
(UTI). They found that, for common diseases and tests, practitioners
overestimate the probability of disease before and after testing. Pretest
probability was overestimated in all scenarios, whereas adjustment in
probability after a positive or negative result varied by test. They conclude
that widespread overestimates of the probability of disease likely contribute
to overdiagnosis and overuse.
Wolf
et al. (Wolf 2021) note many different approaches to reduce
low-value care in adults have been used, including reimbursement restriction,
risk sharing, patient and clinician education, audit and feedback of clinician performance,
and clinical decision support tools. They note that that multicomponent
interventions may be most successful.
Focusing
on the fiscal costs of low-value care and medical overuse can stay in the realm
of administrators and health policy wonks. But it has done little to solve the
problem. Focusing on the human costs of low-value care and medical
overuse is what is needed to get the attention of clinicians, who are key to
solving the problem. You’ve heard us extol over and
over the power of stories over statistics. One example we often note in our
presentations and webinars was from Richard Shannon, MD back in 2007 at a
conference on patient safety sponsored by the NY State Department of Health. He
spoke about how for years data would be presented on rates of CLABSI’s and
likely costs due to CLABSI’s and how this generated little interest in action.
Then something caught his attention: over half his ICU patient who got a CLABSI
died! That’s what spurred him and his colleagues to
action, resulting in a dramatic reduction in CLABSI’s in his ICU. It’s that focus on the impact on our patients, rather than
the pocketbook, that gets clinicians to act.
References:
Fisher
ES, Welch HG. Avoiding the unintended consequences of growth in medical care:
how might more be worse? JAMA.1999; 281(5): 446-553
https://jamanetwork.com/journals/jama/article-abstract/188743
Korenstein
D, Chimonas S,
Barrow B, Keyhani S,
Troy A, Lipitz-Snyderman
A. Development of a
conceptual map of negative consequences for patients of overuse of medical
tests and treatments. JAMA Intern Med 2018; 178(10):
1401-1407
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2696732
Choosing
Wisely
JAMA Internal
Medicine “Less is More” series
https://jamanetwork.com/collections/44045/less-is-more
Ganguli
I, Lupo C, Mainor AJ, et al. Prevalence and Cost of
Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract
Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med 2019; 179(9):
1211-1219
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2735387?resultClick=1
Curry SJ, Krist AH,
Owens DK, et al; US Preventive Services Task Force. Screening for
cardiovascular disease risk with electrocardiography: US Preventive Services
Task Force Recommendation Statement. JAMA 2018; 319(22): 2308-2314
https://jamanetwork.com/journals/jama/fullarticle/2684613
Ganguli
I, Lupo C, Mainor AJ, et al. Assessment of Prevalence
and Cost of Care Cascades After Routine Testing During the Medicare Annual
Wellness Visit. JAMA Netw Open 2020; 3(12): e2029891
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774080?resultClick=1
Bouck Z, Calzavara AJ, Ivers NM, et al. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among
Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA
Intern Med 2020; 180(7): 973-983
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2766917
Ganguli
I, Simpkin AL, Lupo C, et
al. Cascades of Care After Incidental Findings in a US National Survey of
Physicians. JAMA Netw Open 2019; 2(10): e1913325
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2752991?resultClick=1
Chalmers
K, Smith P, Garber J, et al. Assessment of Overuse of Medical Tests and Treatments
at US Hospitals Using Medicare Claims. JAMA Netw Open
2021; 4(4): e218075
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2779118?resultClick=3
Lown Institute. 2021 Winning Hospitals: Avoiding Overuse
Young
GJ, Zepeda ED, Flaherty S, Thai N. Hospital Employment of Physicians In Massachusetts Is Associated With Inappropriate Diagnostic
Imaging. Health Affairs 2021; 40(5):710-718
https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.01183
Müskens JLJM, Kool RB, van Dulmen
SA, et al. Overuse of diagnostic testing in healthcare: a systematic review. BMJ
Quality & Safety 2021; Published Online First: 10 May 2021
https://qualitysafety.bmj.com/content/early/2021/05/09/bmjqs-2020-012576
Brownlee
S, Chalkidou K, Doust J, et
al. Evidence for overuse of medical services around the world. Lancet 2017; 390(10090):
156-168
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32585-5/fulltext
Badgery-Parker T, Pearson S, Dunn S, Elshaug
AG. Measuring Hospital-Acquired Complications Associated With
Low-Value Care. JAMA Intern Med 2019; 179(4): 499-505
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725081
Anderson
TS, Lin GA. Testing Cascades—A Call to Move From
Descriptive Research to Deimplementation Science. JAMA
Intern Med 2020; 180(7): 984-985
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2766913
Henderson
J, Bouck Z, Holleman R, et al. Comparison of Payment
Changes and Choosing Wisely Recommendations for Use of Low-Value Laboratory
Tests in the United States and Canada. JAMA Intern Med 2020; 180(4): 524-531
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2760344
Wolf
ER, Krist AH, Schroeder AR. Deimplementation
in Pediatrics: Past,
Present, and Future. JAMA Pediatr 2021; 175(3):
230-232
https://jamanetwork.com/journals/jamapediatrics/article-abstract/2772456
Morgan
DJ, Pineles L, Owczarzak J,
Magder L, Scherer L, Brown JP, Pfeiffer C, Terndrup C, Leykum L, Feldstein
D, Foy A, Stevens D, Koch C, Masnick M, Weisenberg S, Korenstein D.
Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After
Testing. JAMA Intern Med 2021; Apr 5:e210269
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2778364
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