To Expand the Evidence Base About Harms from Tests and Treatments

Drivers of low-value diagnostic tests in emergency medicine practice: a qualitative descriptive study

INTRODUCTION

Low-value diagnostic tests harm patients and healthcare systems. Elucidation of determinants of low-value tests is essential for their de-implementation. The aim of this study was to understand the drivers of low-value tests in emergency medicine (EM) practice.

METHODS

A qualitative descriptive study was conducted at an Australian academic ED. Purposive sampling was used to recruit participants. Semistructured interviews were used to collect data between February 2023 and May 2023. Interviews were audio-recorded, transcribed verbatim and uploaded to NVivo. Data were thematically analysed through line-by-line and axial coding. Codes were assigned to categories, subthemes and themes. Themes were further analysed using the behavioural domains of the Theoretical Domains Framework. Trustworthiness was ensured through reflexivity, data triangulation, thick description, audit trail and member checking.

RESULTS

Twenty-four interviews were conducted with participants who had a breadth of EM experience: 19 senior EM doctors and 5 doctors in EM training. Low-value tests were inherently understood and unanimously acknowledged by participants. Six drivers of low-value tests emerged: efficiency, culture, resources, complexity, consequences and abilities. Drivers exerted influence at systemic and individual levels by hindering (barriers) or facilitating (enablers) de-implementation of low-value tests. Drivers mapped to the following behavioural domains of the Theoretical Domains Framework: environmental resources and context (resources, complexity, efficiency), social influences (culture), belief about consequences (consequences), and beliefs about capabilities (abilities).

CONCLUSION

An interconnected web of systemic and individual drivers is influencing emergency doctors' behaviour to perform low-value tests. De-implementation of low-value tests will require behavioural change through contemporaneous navigation of multilevel drivers. Behavioural change theories like the Theoretical Domains Framework provide a robust framework to navigate change in collaboration with multidisciplinary clinicians and community. Evidence-based, theory-informed, co-designed interventions are needed to address the drivers of low-value tests.

Social Media Posts About Medical Tests With Potential for Overdiagnosis

Importance

Social media is an influential source of medical information, but little is known about how posts discuss medical tests that carry potential for overdiagnosis or overuse.

Objective

To investigate how social media posts discuss 5 popular medical tests: full-body magnetic resonance imaging, the multicancer early detection test, and tests for antimullerian hormone, gut microbiome, and testosterone.

Design, Setting, and Participants

This cross-sectional study assessed posts on Instagram and TikTok between April 30, 2015, and January 23, 2024, that discussed full-body magnetic resonance imaging, the multicancer early detection test, and tests for antimullerian hormone, gut microbiome, and testosterone. Using keywords on newly created accounts, posts were searched and screened until 100 posts for each test on each platform were identified (n = 1000). Posts were excluded if they did not discuss 1 of the 5 tests or were not in English or if the account holders had fewer than 1000 followers.

Main Outcomes and Measures

The main outcome was information about benefits, harms, and overall tone discussed in the post. All outcomes were summarized descriptively. Logistic regression was used to assess whether the use of evidence or the account holder being a physician or having financial interests influenced how tests were discussed.

Results

A total of 982 posts from account holders with a combined 194 200 000 followers were analyzed. Across all tests, benefits were mentioned in 855 posts (87.1%) and harms in 144 (14.7%), with 60 (6.1%) mentioning overdiagnosis or overuse. Overall, 823 posts (83.8%) had a promotional (vs neutral or negative) tone. Evidence was explicitly used in 63 posts (6.4%), personal anecdotes were used in 333 (33.9%), 498 posts (50.7%) encouraged viewers to take action and get the test, and 668 account holders (68.0%) had financial interests. Posts from physicians were more likely to mention harms (odds ratio, 4.49; 95% CI, 2.85-7.06) and less likely to have an overall promotional tone (odds ratio, 0.53; 95% CI, 0.35-0.80).

Conclusions and Relevance

In this cross-sectional study of social media posts about 5 popular medical tests, most posts were misleading or failed to mention important harms, including overdiagnosis or overuse. These data demonstrate a need for stronger regulation of misleading medical information on social media.

Ethics of Preanesthesia Mandatory Laboratory Testing

Some practices require mandatory preoperative laboratory testing for select patients presenting for anesthesia and surgery. Such mandatory preanesthesia laboratory testing has significant ethical implications related to informed consent and patient autonomy. Assumptions that a patient provides "presumed consent" by merely presenting for a test are flawed because such consents are often not informed and do not acknowledge patient autonomy. By placing a condition on access to a medical treatment, mandatory preanesthesia testing may not be ethically justifiable. Not all laboratory tests are "ethically equal"; several raise specific questions regarding informed consent, related to their potential to cause significant harm.

Women's interest, knowledge, and attitudes relating to anti-Mullerian hormone testing: a randomized controlled trial

STUDY QUESTION

What is the impact of co-designed, evidence-based information regarding the anti-Mullerian hormone (AMH) test on women's interest in having the test?

SUMMARY ANSWER

Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test than women who viewed information produced by an online company selling the test direct-to-consumers.

WHAT IS KNOWN ALREADY

Online information about AMH testing often has unfounded claims about its ability to predict fertility and conception, and evidence suggests that women seek out and are recommended the AMH test as a measure of their fertility potential.

STUDY DESIGN, SIZE, DURATION

An online randomized trial was conducted from November to December 2022. Women were randomized (double-blind, equal allocation) to view one of two types of information: co-designed, evidence-based information about the AMH test (intervention), or existing information about the AMH test from a website which markets the test direct-to-consumers (control). A total of 967 women were included in the final analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women recruited through an online panel, who were aged 25-40 years, living in Australia or The Netherlands, had never given birth, were not currently pregnant but would like to have a child now or in the future, and had never had an AMH test. The primary outcome was interest in having an AMH test (seven-point scale; 1 = definitely NOT interested to 7 = definitely interested). Secondary outcomes included attitudes, knowledge, and psychosocial and behavioural outcomes relating to AMH testing.

MAIN RESULTS AND THE ROLE OF CHANCE

Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test (MD = 1.05, 95% CI = 0.83-1.30), less positive attitudes towards (MD = 1.29, 95% CI = 4.57-5.70), and higher knowledge about the test than women who viewed the control information (MD = 0.75, 95% CI = 0.71-0.82).

LIMITATIONS, REASONS FOR CAUTION

The sample was more highly educated than the broader Australian and Dutch populations and some measures (e.g. influence on family planning) were hypothetical in nature.

WIDER IMPLICATIONS OF THE FINDINGS

Women have higher knowledge of and lower interest in having the AMH test when given evidence-based information about the test and its limitations. Despite previous studies suggesting women are enthusiastic about AMH testing to learn about their fertility potential, we demonstrate that this enthusiasm does not hold when they are informed about the test's limitations.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by an NHMRC Emerging Leader Research Fellowship (2009419) and the Australian Health Research Alliance's Women's Health Research, Translation and Impact Network EMCR award. B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. D.L. is the Medical Director of, and holds stock in, City Fertility NSW and reports consultancy for Organon and honoraria from Ferring, Besins, and Merck. K.H. reports consultancy and travel support from Merck and Organon. K.M. is a director of Health Literacy Solutions that owns a licence of the Sydney Health Literacy Lab Health Literacy Editor. No other relevant disclosures exist.

TRIAL REGISTRATION NUMBER

ACTRN12622001136796.

TRIAL REGISTRATION DATE

17 August 2022.

DATE OF FIRST PATIENT’S ENROLMENT

21 November 2022.

Studying harms of interventions with an equity lens in randomized trials

Equity and health equity are fundamental pillars in fostering a just and inclusive society. While equity underscores fairness in resource allocation and opportunity, health equity aims to eradicate avoidable health disparities among social groups. The concept of harms in interventions-undesirable consequences associated with the use of interventions-often varies across populations due to biological and social factors, necessitating a nuanced understanding. An equity lens reveals disparities in harm distribution, urging researchers and policymakers to address these differences in their decision-making processes. Furthermore, interventions, even well-intentioned ones, can inadvertently exacerbate disparities, emphasizing the need for comprehensive harm assessment. Integrating equity considerations in research practices and trial methodologies, through study design or through practices such as inclusive participant recruitment, is pivotal in advancing health equity. By prioritizing interventions that address disparities and ensuring inclusivity in research, we can foster a more equitable healthcare system.

Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review

Respect for patient autonomy is a pillar of medical ethics, manifested predominantly through informed consent. Mandatory (routine) nonconsented preoperative urine pregnancy testing does not adequately respect patient autonomy, is potentially coercive, and has the potential to cause harm medically, psychologically, socially, and financially. Inaccuracies in pregnancy testing can result in false-positive and false-negative results, especially in early pregnancy. There is substantial scientific evidence that anesthesia is not harmful to the fetus, raising the question of whether pregnancy testing provides substantial benefit to the patient. Not performing a preanesthesia pregnancy test has not been associated with significant medicolegal consequences. We review the ethical implications of mandatory preanesthesia pregnancy testing in light of these facts.

Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines

BACKGROUND

Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer.

OBJECTIVE

To describe current reporting practices and identify opportunities for improvement.

DESIGN

Review of guidelines.

SETTING

United States.

PATIENTS

Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines.

MEASUREMENTS

Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type.

RESULTS

Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type.

LIMITATIONS

This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines.

CONCLUSION

The review identified opportunities for improving conceptualization, assessment, and reporting of screening process-related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending

IMPORTANCE

Delivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios.

OBJECTIVE

To evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021.

EXPOSURES

At least 1 claim for low-value PSA tests for prostate cancer screening during the observation period.

MAIN OUTCOMES AND MEASURES

Utilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting.

RESULTS

Of 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.

Associations Between Low-Value Medication in Dementia and Healthcare Costs

BACKGROUND

Low-value medications (Lvm) provide little or no benefit to patients, may be harmful, and waste healthcare resources and costs. Although evidence from the literature indicates that Lvm is highly prevalent in dementia, evidence about the financial consequences of Lvm in dementia is limited. This study analyzed the association between receiving Lvm and healthcare costs from a public payers' perspective.

METHODS

This analysis is based on data of 516 community-dwelling people living with dementia (PwD). Fourteen Lvm were extracted from dementia-specific guidelines, the German equivalent of the Choosing Wisely campaign, and the PRISCUS list. Healthcare utilization was retrospectively assessed via face-to-face interviews with caregivers and monetarized by standardized unit costs. Associations between Lvm and healthcare costs were analyzed using multiple linear regression models.

RESULTS

Every third patient (n = 159, 31%) received Lvm. Low-value antiphlogistics, analgesics, anti-dementia drugs, sedatives and hypnotics, and antidepressants alone accounted for 77% of prescribed Lvm. PwD who received Lvm were significantly less cognitively impaired than those not receiving Lvm. Receiving Lvm was associated with higher medical care costs (b = 2959 €; 95% CI 1136-4783; p = 0.001), particularly due to higher hospitalization (b = 1911 €; 95% CI 376-3443; p = 0.015) and medication costs (b = 905 €; 95% CI 454-1357; p < 0.001).

CONCLUSION

Lvm were prevalent, more likely occurring in the early stages of dementia, and cause financial harm for payers due to higher direct medical care costs. Further research is required to derive measures to prevent cost-driving Lvm in primary care, that is, implementing deprescribing interventions and moving health expenditures towards higher value resource use.

Short and long-term psychosocial consequences of participating in a colorectal cancer screening programme: a matched longitudinal study

OBJECTIVES

To investigate the psychosocial consequences of receiving a false-positive (no abnormalities) result or being diagnosed with polyps compared with receiving a negative result in a colorectal cancer (CRC) screening programme.

DESIGN AND SETTING

This was a longitudinal study nested in the roll-out of the Danish CRC screening programme that targets all individuals aged 50-74 years.

PARTICIPANTS

In the inclusion period (April-September 2017), all positive screenees (n=1854) were consecutively enrolled and matched 2:1:1 on sex, age (±2 years), municipality and screening date with negative screenees (n=933) and individuals not yet invited to screening (n=933).Questionnaires were sent by mail to all eligible participants in Region Zealand, Denmark, after the screening result, 2 months and 12 months after the final result.Positive screenees who did not receive the follow-up procedure were excluded.

MAIN OUTCOME MEASURES

The primary outcomes were psychosocial consequences. Outcomes were measured with the CRC screening-specific questionnaire Consequences of screening in CRC with 11 outcomes after the screening result and with 21 outcomes at the two later assessments.

RESULTS

After receiving the screening result, individuals with no abnormalities, low-risk and medium-risk and high-risk polyps scored significantly worse on 8 of 11 outcomes compared with the negative screenee group. At the 12-month follow-up, the differences were still significant in 8 of 21 outcomes (no abnormalities), 4 of 21 outcomes (low-risk polyps) and 10 of 21 outcomes (medium-risk and high-risk polyps). The negative screenee group and the group not yet invited to screening differed psychosocially on 5 of 11 outcomes after the screening result, but on none of the 21 outcomes at the 2 months and 12 months follow-up.

CONCLUSIONS

The study showed that there are both short-term and long-term psychosocial consequences associated with receiving a no abnormalities result or being diagnosed with polyps. The consequences were worst for individuals diagnosed with medium-risk and high-risk polyps.

Longitudinal Content Analysis of the Characteristics and Expected Impact of Low-Value Services Identified in US Choosing Wisely Recommendations

IMPORTANCE

The US Choosing Wisely campaign has had substantial reach in mobilizing efforts to reduce low-value care, achieved largely by engaging physician specialty societies in stewardship. While some early recommendations were criticized for avoiding revenue-generating services, there is limited evidence of how the composition of recommendations shifted as more societies contributed.

OBJECTIVE

To analyze the characteristics and expected impact of Choosing Wisely recommendations.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included content and trend analyses of all 626 Choosing Wisely recommendations by US physician societies as of March 1, 2021. Data were analyzed between March and May 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were proportions of identified low-value services by characteristics (society type, service type, indication, do vs avoid, and clinical context) and expected impact (effect on the revenue of society members, cost, number of individuals at risk, direct harm potential, and cascade potential).

RESULTS

Low-value services identified in the 626 Choosing Wisely recommendations largely covered imaging (168 [26.8%]) and laboratory studies (156 [24.9%]) in the context of chronic conditions (169 [27.0%]) and healthy patients with risk factors alone (126 [20.1%]). Most of the identified low-value services were revenue neutral for the recommending society (402 [64.2%]) and the plurality were low cost (<$200; 284 [45.4%]); low-cost services represented a growing share of low-value services identified by Choosing Wisely recommendations (1.2 percentage points per year; P = .001). Nearly half (280 [44.7%]) of recommendations identified services with high direct harm potential, and 388 (62.0%) identified those with high potential for cascades (ie, triggering downstream services).

CONCLUSIONS AND RELEVANCE

The results of this qualitative study suggest that the Choosing Wisely recommendations identified services with a range of expected impacts. Stakeholders could explicitly set priorities for future recommendations, while clinical leaders and payers might target intervention efforts on recommendations with the greatest potential for impact based on spending across populations, direct harms, and cascades.

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

Question

What is the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may be low value?

Findings

In this retrospective claims analysis of a cohort of Medicare fee-for-service beneficiaries, there were 231 HACs and 1764 PSIs in 197 755 claims for 7 inpatient procedures from 2016 to 2018.

Meaning

Patients with flagged, potential low-value procedures were harmed while in hospital, resulting in an extended length of stay and additional costs.

Importance

There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population.

Objective

To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs.

Design, Setting, and Participants

This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020.

Main Outcomes and Measures

For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs), as well as the unadjusted and adjusted difference in mean LOS and Medicare costs between admissions with and without a HAC/PSI. For outpatient procedures, we report the number of claims where the beneficiary had an unplanned hospital admission within seven days and the number of these admissions with a HAC/PSI.

Results

There were 573 351 patients included in the study, with 617 264 procedures; the mean (SD) age was 74.2 (6.7) years, with 320 637 women (55.9%), and mostly White patients (520 735; 90.8%). Among the 197 755 claims for the inpatient procedures, 231 had an HAC and 1764 had a PSI. Spinal fusion was associated with the most HACs (123 admissions) and PSIs (1015 admissions). Overall, HACs during a PCI admission were associated with the highest adjusted additional mean LOS (17.5 days; 95% CI, 10.3-23.6), with also the highest adjusted additional mean cost ($22 000; 95% CI, $9100-$32 600). There were 419 509 included outpatient procedures, and 7514 (1.8%) had an unplanned admission within 7 days. A total of 17 HACs and PSIs occurred in these admissions.

Conclusions and Relevance

In this cross-sectional cohort study of Medicare fee-for-service claims, patients receiving potential low-value care were exposed to risk of unnecessary harm associated with higher cost and LOS.