Low-value screening in primary care often leads to specialist care

ByJanel Miller

Low-risk patients in Canada who received Pap tests, chest X-rays or ECGs as part of an annual health examination were more likely to have subsequent specialist care than untested patients, a population-based cohort study showed.

Perspective from Leonard Samuel Feldman, MD

“A recent study demonstrated that routine tests in low-risk patients conducted as part of an annual health examination in primary care are performed frequently,” Zachary Bouck, research associate at St. Michael's Hospital in Toronto, and colleagues wrote in JAMA Internal Medicine. “However, whether these screening tests are associated with increased downstream clinical service use is unknown to date.”

In the United States, low-value services cost the health care system an estimated $75.7 and to $101.2 billion annually, according to the researchers.

Bouck and colleagues assessed the probability of low-risk patients who received Pap tests (29,194 patients; mean age, 45.5 years); chest X-rays for CVD and pulmonary disease (43,532 patients; mean age, 47.5 years; 38.5% women) or ECGs for CVD (245,686 patients; mean age, 49.9 years; 51.1% women) to receive follow-up care vs. patients who did not receive these same tests.

After 90 days since the examination, chest X-rays in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) patients having an outpatient pulmonology visit and 1.96 (95% CI, 1.71-2.22) patients having an abdominal or thoracic CT scan per 100 patients. Over the same time period, ECGs in low-risk patients were tied to an additional 1.92 (95% CI, 1.82-2.02) patients having an outpatient cardiologist visit; 5.49 (95% CI, 5.33-5.65) patients having a transthoracic echocardiogram; and 4.46 (95% CI, 4.31-4.61) patients having a cardiac stress test.

After 180 days since the examination, the researchers found that Pap testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78) patients having an outpatient gynecology visit; 52.8 (95% CI, 51.9-53.6) patients having a follow-up Pap test; and 0.84 (95% CI, 0.66-1.01) patients having a colonoscopy per 100 patients.

“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,” Bouck and colleagues wrote. “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.”

Although the results support existing research, Timothy Anderson, MD, of the division of general medicine at Beth Israel Deaconess Medical Center, and colleagues wrote in a related editorial that the findings are limited because they are based on administrative data.

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Thus, Anderson and colleagues suggested that approaches that more accurately characterize testing cascades and outcomes, ascertain the drivers of low-value testing and evaluate interventions to reduce its use may offer a better understanding of its efficacy.

“Successful efforts to de-implement low-value practices will require an alignment of interests and an understanding of the negative consequences of routine testing beyond costs,” they wrote.

References:

Perspective

Leonard Samuel Feldman, MD

Though Bouck and colleagues conducted their study in Canada, its findings are extremely relevant to physicians in the United States. It is critical that physicians think about the downstream costs when providing services, especially screening services, to patients.

Every physician deals with risk in his or her own way. No one wants to be the physician that misses something that we could have diagnosed. Very risk-averse physicians choose to do more screening tests to make sure they do not miss something and are the physicians who usually end up with more false-positive results. Those false-positive results have consequences. The mental anguish, costs and other possible morbidities (i.e., the downstream effects) that a patient incurs when working up false positives is not trivial.

That said, evidence-based screening typically tends to improve people’s lives. When trying to decide the value of a screening test, I would recommend physicians look at the data. For example, data do not suggest that annual CT scans decrease mortality for pancreatic cancer. So, avoid CT scans for that purpose. Physicians almost never have the time to look for the data on their own. Instead, we turn to professional groups that create clinical guidelines that weigh the benefits and risks of screening in order to decide whether to recommend it.

Leonard Samuel Feldman, MD

Associate professor of medicine and pediatrics,

Johns Hopkins Medicine

Disclosures: Feldman reports no relevant financial disclosures.

Sources/Disclosures

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Source: Bouck Z, et al. JAMA Intern Med. 2020;doi:10.1001/jamainternmed.2020.1611.

Disclosures: Anderson reports receiving grants from the National Institute on Aging and the American College of Cardiology. Bouck reports no relevant financial disclosures. Lin reports 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, as well as contract work from the Institute for Clinical and Economic Review. Please see the study for all other authors’ relevant financial disclosures.

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Low-value screening in primary care often leads to specialist care

References:

Perspective

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