Cascades of Care After Incidental Findings in a US National Survey of Physicians

Abstract

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally.

Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.

Design, setting, and participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.

Main outcomes and measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.

Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). 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% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this 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 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.

Conclusions and relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Figure 1.. Reported Events and Outcomes of Cascades Following Incidental Findings in the Past Year

Values are weighted percentages. There were no missing data. For this analysis, 2 respondents who reported that they experienced no cascades were excluded. The figure shows the distribution of responses to a series of questions: “In the past year, how often did you experience an incidental finding for your patient that led to each of the following?” “Physician harm” included anxiety, frustration, and wasted time and effort. “Patient harm” included physical or psychological harm, treatment burden, disrupted social relationships or status, financial burden, dissatisfaction with care, and death.

Figure 2.. Features of 371 Physicians’ Most Recent Cascades of Care After Incidental Findings

Values are weighted percentages. For this analysis, we excluded 2 respondents who reported that they experienced no cascades and 3 respondents for whom it was not possible to assign responses about their most recent cascades to the given categories (eg, the initial event was reported to be a procedure or a panel of unspecified tests). The figure shows the distribution of responses to a series of questions after the following statement: “Thinking back to the last time you experienced any cascade from an incidental finding for your patient….” This “Sankey” diagram shows the percentage of physicians who gave each possible response to questions about their most recently experienced cascade. The heights of the question response boxes are proportional to the percentage of physicians who chose each response (shown in parentheses after the response); the heights of the connecting lines are proportional to the percentage of physicians who then chose the subsequent response. This diagram visualizes the “flow” of the reported cascades from how they started (Who ordered the initial test?) to their outcomes (Did the cascade cause patient or physician harm?). Initial test “Other” includes cardiac, urine, stool, microbiology, and pathology tests.