Physicians Pursue Incidental Findings for Nonclinical Reasons

Diana Swift

August 01, 2019

On a routine preoperative electrocardiogram performed before low-risk cataract surgery, something unexpected and of unclear import shows up. In a scenario such as this involving incidental test findings, many US physicians feel compelled to pursue downstream test/treatment cascades, even when such costly follow-up is not clinically necessary, a Web-based survey of 376 physicians indicates.

One solution may be to change the norms of physicians' practice communities, according to lead author Ishani Ganguli, MD, MPH, an internist at Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts, and colleagues.

In deciding whether to take the follow-up pathway, 57.6% of respondents said they would give precedence to a specialist's recommendation over current clinical guidelines. In the absence of guideline evidence, 62.4% would undertake further tests.

"Altogether, our results suggest the need to motivate cost-conscious, pragmatic decision-making throughout training and practice, as well as peer support mechanisms, especially following a malpractice suit," Ganguli and coauthors write in an article published online July 25 in the Journal of General Internal Medicine.

"There's been a lot of thinking and research recently about low-value medical care, that is, care in which any potential benefit is outweighed by potential harm," Ganguli told Medscape Medical News. "We wanted to understand physicians' perspectives on incidental findings, how often they follow up, and what drives that decision when further testing may not be needed," she said. Unexpected findings are commonly encountered by physicians in practice, and often at the end of the follow-up cascade, not much of significance is found, Ganguli added.

Her group recently conducted a study that showed that care cascades following preoperative electrocardiography for cataract surgery were uncommon but expensive and could be a target for cost-saving intervention. In another recent analysis of physician variation in providing wasteful medical services, the mean annual rate of low-value services was 33.1 per 100 Medicare beneficiaries; there was considerable variation across regions and organizations.

Survey Details

From January 22 to March 2, 2019, the investigators polled a random sample of American College of Physicians members who practiced general outpatient medicine; 44.7% of the initial sample responded. The primary outcome was physicians' decisions to pursue further evaluation of incidental findings of uncertain significance when guidelines did not recommend further testing but a specialist did or when guideline evidence was lacking.

Respondents were asked to decide on a course of action in response to two clinical scenarios involving otherwise healthy patients about to undergo knee surgery. In the first vignette, a 60-year-old man undergoes a routine preoperative chest x-ray that shows a pulmonary nodule. A CT scan confirms the presence of a 5-mm mass. The radiology report recommends a repeat CT scan in 6 to 12 months, whereas the Fleischner Society recommendations specify no further action for low-risk patients with nodules of <6 mm.

Asked about their next step, 37.3% of participants said they would repeat the CT scan; 41.7% said they would take no further action. An additional 17.3% said they would decide after consulting a specialist, such as a radiologist, pulmonologist, or thoracic surgeon.

In a second vignette, a 30-year-old woman undergoes a routine preoperative complete blood count, which is normal except for slightly low hemoglobin and hematocrit levels, which might be related to her menstrual cycle.

In responding to this vignette, 41.7% of participants said they would order a repeat complete blood count in 1 to 4 weeks; 20.7% would order further tests, such as stool guaiac and iron studies; and 37.5% would take no further steps.

"A surprising number of physicians when told not to do something would go ahead and do the opposite, and that's concerning," said Peter A. Ubel, MD, director of the Center for Behavioral and Decision Sciences in Medicine at Duke University in Durham, North Carolina. He was not involved in the survey.

Ubel told Medscape Medical News, "We don't know much about the characteristics of doctors who are most likely to do things they shouldn't do, but knowing these is not really helpful anyway. The real challenge is to look at what medicine does too much of and persuade doctors to stop doing it," Ubel added.

The survey also asked physicians to recall their most recent care cascade that occurred in real-life practice; 364 of 376 respondents reported they had personally pursued an incidental finding. Of these, 58.6% said they did so because it "seemed clinically important." Of the remaining 41.4%, the most frequent reasons (not mutually exclusive) for follow-up were practice or community norms (49.7%), concern about a lawsuit (35.7%), another physician's advice (26.0%), and patient request (24.2%).

Physicians who had already experienced a malpractice lawsuit were understandably more likely to pursue follow-up testing out of concern for being sued again (44.3% vs 27.6%; P = .002). Peer support group discussions or counseling may help physicians who face this potentially traumatic event, Ganguli said.

The researchers assessed the pursuit of incidental findings with respect to various physician characteristics. They found that US-trained physicians and those with a lower level of cost consciousness were more likely to take follow-up action that was not recommended by guidelines. This, the researchers say, may reflect values and training acquired in settings with greater resources.

Factors such as physician age, sex, urban vs rural practice, patient education level, and geographic region had no predictive impact. "The lack of other significant predictors mirrors claims-based studies on low-value care and points to unmeasured traits like physicians' statistical knowledge or their working relationships with radiologists that might be explored further," the authors write.

Also commenting on the study for Medscape Medical News, Jeffrey T. Kullgren, MD, MPH, said the survey is "important and intriguing," but he highlighted the difficulty of teasing out physician characteristics that drive the follow-up cascade. Kullgren is an assistant professor of medicine at the University of Michigan Medical School and the Institute for Healthcare Policy and Innovation in Ann Arbor. He and did not participate in the study.

"There's not a lot of easy answers about the kind of doctors doing this," he said. Given the concern within medicine about reducing wasteful, low-value testing, "there's a need to educate not just older doctors in practice for a long time but younger doctors in training about what follow-up is most likely to benefit patients."

Kullgren was also intrigued but was not surprised by the number of physicians who seemed to put as much faith in the expert opinion of colleagues as they did in professional society guidelines. "This disconnect can result from a host of factors. First, the effects of guidelines can take a long time to be felt, and guidelines are not always as effective as intended," he said. "And sometimes the expertise and recommendations of a specialist you know in the same healthcare organization may carry more weight and be more trusted than guidelines."

In line with that, Medscape Medical News previously reported on research that concluded that primary care providers' relationships with radiologists may affect the way they react to incidental findings and that radiologists can help guide decisions with recommendations developed on the basis of evidence rather than opinion.

Ultimately, said Kullgren, physicians' motivation to order more tests "comes from a very good place. We develop an instinct during training to do as much as we can to help patients and to explain any abnormalities. But sometimes we need to put the brakes on that instinct."

Added Ganguli, "The need to follow up can feel compelling to doctors. Whether older or younger, all clinicians feel this pressure. The take-away message is we need better tools to help guide decisions about follow-up."

The study was supported by a grant from the Agency for Healthcare Research and Quality. The authors, Ubel, and Kullgren have disclosed no relevant financial relationships.

J Gen Intern Med. Published online July 25, 2019. Abstract

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