Incidental findings: expect to find the unexpected

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

“…43,44 Meanwhile, physicians may feel distress, decision-making conflict, or burden from the added work of following up the initial abnormality. 10,11,40,42 We found that factors associated with cascades mirrored those associated with the low-value services themselves. Our results confirm findings from earlier work that preoperative testing for cataract surgery is more common among older, sicker individuals who live in urban areas and that there is greater use of low-value services in areas with more specialists and spending per capita.…”

“…[45][46][47] This builds on previous work suggesting that cascades after incidental findings may be driven by clinician desire to have more information, ensure patient safety, assuage medicolegal risk, or meet the perceived or real expectations of patients or other clinicians. 1,11,12,18,[40][41][42][48][49][50][51][52] Although we cannot pinpoint in this claims-based analysis which potential cascade events followed directly from the preoperative EKG (eg, the most prevalent new diagnoses were identical in our EKG and comparison groups, reflecting cardiac conditions common in the Medicare population), we note that recipients of preoperative EKGs had higher rates of cardiac specialist visits coded with primary diagnosis of an unspecified "abnormal finding." Similarly, a medical record review of ophthalmic preoperative examinations found that these examinations uncovered EKG abnormalities such as firstdegree atrioventricular block and bradycardia, 27 diagnoses that can be of limited clinical importance yet have the potential to lead to further testing and treatment.…”

“…Although we purposefully chose an initial service whose low value at a population level is well established in the literature, in some individual cases, the test may have resulted in care that improved health. 39 But on average, such cascades are likely to come at a cost to patients, clinicians, and payers [9][10][11][12] : in addition to the financial cost, patients might experience anxiety, risks associated with treatment, inconvenience, and opportunity costs owing to time spent on office visits or procedures 9,11,[40][41][42] or from the bur- 43,44 Meanwhile, physicians may feel distress, decision-making conflict, or burden from the added work of following up the initial abnormality. 10,11,40,42 We found that factors associated with cascades mirrored those associated with the low-value services themselves.…”

“…39 But on average, such cascades are likely to come at a cost to patients, clinicians, and payers [9][10][11][12] : in addition to the financial cost, patients might experience anxiety, risks associated with treatment, inconvenience, and opportunity costs owing to time spent on office visits or procedures 9,11,[40][41][42] or from the bur- 43,44 Meanwhile, physicians may feel distress, decision-making conflict, or burden from the added work of following up the initial abnormality. 10,11,40,42 We found that factors associated with cascades mirrored those associated with the low-value services themselves. Our results confirm findings from earlier work that preoperative testing for cataract surgery is more common among older, sicker individuals who live in urban areas and that there is greater use of low-value services in areas with more specialists and spending per capita.…”

“…But on average, such cascades are likely to come at a cost to patients, clinicians, and payers: in addition to the financial cost, patients might experience anxiety, risks associated with treatment, inconvenience, and opportunity costs owing to time spent on office visits or procedures or from the burden of a new diagnosis . Meanwhile, physicians may feel distress, decision-making conflict, or burden from the added work of following up the initial abnormality …”