99% Of Doctors Have Faced This Diagnostic Dilemma

A patient goes for a routine electrocardiogram before cataract surgery and is told that the readout showed a nonspecific finding. This sets into motion a series of tests and procedures—a cascade of additional medical care—that includes a stress test and then cardiac catheterization, which ultimately shows no cardiovascular disease. Such chains of events happen all the time.

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According to the results of a national survey, 99% of physicians said they’ve experienced these cascades, which have caused their patients psychological harm, physical harm, and financial burden. Plus, these cascades also cause frustration and anxiety for physicians, survey investigators reported in a recent article in JAMA Network Open.

“Our findings are both shocking and not surprising at all. Every clinician I have ever spoken to has experienced an incidental finding that led to downstream care that didn’t help a patient in the long run,” said corresponding author Ishani Ganguli, MD, MPH, physician researcher, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA.

Dr. Ganguli and coauthors defined incidental findings as “actionable results that are unrelated to why one ordered the tests” and characterized a cascade arising from such a finding as “additional medical care, such as telephone calls, office visits, further testing, and treatment.”

Although incidental findings sometimes reveal a clinically important discovery—such as early stage cancer—follow-up evaluations more often find nothing, indicated Dr. Ganguli, who is also an assistant professor of medicine at Harvard Medical School.

The researchers believe this is the first study of its kind to examine, on a national scale, the scope of incidental findings and subsequent cascades of care.

Don’t go chasing waterfalls

For this study, Dr. Ganguli and colleagues developed an online survey that asked a nationally representative sample of US internists about their experiences with cascades and potential solutions. Of the 376 physicians who responded, nearly all (99.4%) said they had experienced a cascade.

Most physicians experienced a cascade that led to a new invasive test for their patient (77.2%), emergency department visit (54.8%), or hospitalization (50.6%). Physicians also reported that cascades of additional care often included phone calls with patients (21.7% reported them at least weekly), new noninvasive tests (16.1% at least weekly), and repeated tests (14.7% at least weekly).

When asked about their most recent cascade, one-third of physicians (33.7%) reported that the initial test that revealed the incidental finding may not have been clinically appropriate.

Also, approximately half of physicians said they had experienced a cascade when they or their family members were patients.

A large majority of physicians (90.9%) reported experiencing cascades with clinically important and intervenable outcomes, such as the discovery of a chronic condition (64.7%), cancer (59.0%), or an acute medical problem (36.6%). But even more physicians (94.4%) said they’d had cascades with no such outcomes.

When asked about the frequency of these cascades, physicians reported more cascades with no clinically important or intervenable outcome (31.1%) than those with meaningful outcomes (14.8%), on at least a monthly basis.

However, on a yearly basis, physicians reported more cascades with clinically meaningful outcomes than those without.

In an invited commentary, John Mandrola, MD, Division of Cardiac Electrophysiology, Baptist Health, Louisville, KY, and Daniel J. Morgan, MD, MS, University of Maryland School of Medicine, Baltimore, MD, wrote: “[W]hile the survey reveals that physicians often experience cascades from incidental findings that cause harm, nearly as many physicians report good outcomes from the workup of an incidental finding. A nonspecific finding on an electrocardiogram is more likely to lead to unnecessary, costly, and potentially harmful cardiac testing, but it sometimes finds a left main coronary lesion.”

Why do doctors pursue cascades?

In a related study published earlier this year, Dr. Ganguli and coauthors submitted clinical vignettes to the same 376 internists in the survey discussed above. After reviewing these vignettes, 62.4% of physicians said they would do further testing in the absence of guiding evidence.

When considering their own most recent cascade, 58.6% of respondents who reported pursuing follow-up of an incidental finding did so because it “seemed clinically important.” But the remaining 41.4% of respondents reported that they did so for reasons other than clinical importance. Of these reasons, their most common ones were practice/community norms (49.7%), concern about a lawsuit (35.7%), another doctor’s advice (26.0%), and patient request (24.2%). (Respondents could choose more than one answer.)

Dr. Mandrola and Dr. Morgan wrote: “Another potential cause of cascades turns on cultural expectations. Harm from overzealous screening is underrecognized. The general public is inundated with disease-of-the-month campaigns, but there are no overdiagnosis awareness months.”

What can be done?

Physicians appear to be aware of the problems of pursuing incidental findings, and identified several potential solutions to try to halt cascades:

• 62.8% asked for accessible guidelines on how to manage incidental findings.
• 48.1% pointed to patient and clinician education on potential harms from unnecessary medical care.
• 44.6% identified decision aids (ie, shared decision-making tools).
• 42.0% suggested malpractice reform.

Some physicians also thought that patient cost-sharing (18.1%) or value-based payment models (16.2%) would help.

“For many tests, providing the sensitivity and specificity with the test result could remove a barrier to accurate interpretation,” suggested Dr. Mandrola and Dr. Morgan. “For other tests, a report could contain information on the frequency of incidental findings, what results from those findings, and what options are available for workup. The movement in radiology to include evidence-based recommendations when reporting incidental nodules is a good first step.”

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