Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit

Abstract

Key Points Question What are the prevalence of low-value testing during Medicare annual wellness visits and of cascades of medical services and new diagnoses that might follow? Findings In this cohort study of 75 275 fee-for-service Medicare beneficiaries aged 66 and older who received an annual wellness visit, 19% of beneficiaries received at least 1 routine electrocardiogram, urinalysis, or thyrotropin test during their visit, more often those who were younger and lived in urban, high-income areas. An estimated 6 cascade-attributable events per 100 electrocardiogram recipients and 5 events per 100 urinalysis recipients occurred in the subsequent 90 days. Meaning In this study, a minority of healthy Medicare beneficiaries received routine tests during their annual wellness visits, and low-value electrocardiograms and urinalyses were associated with cascades of care.

Racial differences in low‐value pediatric emergency care in general emergency departments

“…Disparities have typically been highlighted in the context of underuse and poorer clinical outcomes among non‐White patients 1,7 . However, there are risks associated with low‐value care, including incidental findings and false‐positive tests, which can lead to care cascades which are associated with further unnecessary testing and treatments, radiation exposure, and costs 8,9 . Although the provision of low‐value care appears in our study to directly affect non‐White patients greater than non‐Hispanic Black and Hispanic patients, these results may be viewed also in the greater context of minority patients receiving fewer tests and interventions.…”

“…1,7 However, there are risks associated with low-value care, including incidental findings and false-positive tests, which can lead to care cascades which are associated with further unnecessary testing and treatments, radiation exposure, and costs. 8,9 Although the provision of low-value care appears in our study to directly affect non-White patients greater than non-Hispanic Black and Hispanic patients, these results may be viewed also in the greater context of minority patients receiving fewer tests and interventions. The extent to which these disparities are due to implicit and explicit biases 10 and parental preferences is not known but deserves further study.…”

Downstream Mammary and Extramammary Cascade Services and Spending Following Screening Breast Magnetic Resonance Imaging vs Mammography Among Commercially Insured Women

“…The increasing use of screening breast MRI, especially among women with low or average-risk for breast cancer, raises concerns about the extent to which these studies trigger downstream cascades of care that may have limited value and entail potential harm for patients. 12 , 13 , 14 , 15 , 16 , 17 Breast MRI is less specific than mammography for breast pathology, 4 , 18 resulting in more false-positive results and unnecessary biopsies. 19 , 20 , 21 In addition, unlike mammography, breast MRI can reveal extramammary findings that may similarly prompt follow-up imaging and other services of unclear benefit.…”

“…We used commercial claims data from across the US to compare women receiving breast MRI vs mammography screening on rates of downstream laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses that could potentially follow mammary and extramammary findings on breast MRI, building on methods developed in prior work. 12 , 13 , 27 We also compared total and patient out-of-pocket spending on cascade services and overall.…”

Running the Numbers : Capitalize on the Moment: Leveraging the COVID-19 Experience to Spur Low-Value Care Reduction in North Carolina

“…This could aid recovery of primary and preventive services and reach high-risk patient populations. Conversely, telehealth coverage and reimbursement could be eliminated or reduced for known low-value services, especially those known to set off cascades of costly and preventable downstream care (e.g., emergency room use, specialty referral, imaging) often fueled by the desire to avoid even the smallest risk of a serious condition [11,12]. This succession of medical services can follow from incidental or marginal findings on screening and diagnostic tests, some of which are themselves of low value.…”