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Original Investigation
Less Is More
June 8, 2020

Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination

Author Affiliations
  • 1Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
  • 2Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 3ICES, Toronto, Ontario, Canada
  • 4Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 5VA Center for Clinical Management Research, Ann Arbor, Michigan
  • 6Department of Internal Medicine, University of Michigan, Ann Arbor
  • 7Michigan Program on Value Enhancement, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
  • 8Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 9Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 10Division of General Internal Medicine and Geriatrics at Sinai Health System and University Health Network, Toronto, Ontario, Canada
JAMA Intern Med. Published online June 8, 2020. doi:10.1001/jamainternmed.2020.1611
Key Points

Question  Are primary care patients who undergo low-value testing as part of an annual health examination (AHE) more likely to receive subsequent care than patients who do not?

Findings  In this population-based cohort study of low-risk patients undergoing an AHE, patients who received a low-value screening test (chest radiograph [n = 43 532], electrocardiogram [n = 245 686], or Papanicolaou test [n = 29 194]) on the date of or shortly after their AHE were at increased risk of subsequent specialist visits, diagnostic tests, and procedures in the following 90 and 180 days.

Meaning  These findings suggest that low-value testing of primary care outpatients contributes to further downstream care.


Importance  The association of low-value testing with downstream care and clinical outcomes among primary care outpatients is unknown to date.

Objective  To assess the association of low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE).

Design, Setting, and Participants  This population-based retrospective cohort study used administrative health care claims from Ontario, Canada, for primary care outpatients undergoing an AHE between April 1, 2012, and March 31, 2016, to identify individuals who could be placed into one (or more) of the following 3 cohorts: adult patients (18 years or older) at low risk for cardiovascular and pulmonary disease, adult patients at low risk for cardiovascular disease, and female patients (aged 13-20 years or older than 69 years) at low risk for cervical cancer. The dates of analysis were June 3 to September 12, 2019.

Exposures  Low-value screening tests were defined per cohort as (1) a chest radiograph within 7 days, (2) an electrocardiogram (ECG) within 30 days, or (3) a Papanicolaou test within 7 days after an AHE.

Main Outcomes and Measures  Subsequent specialist visits, diagnostic tests, and procedures within 90 days after a low-value test (if the patient had a chest radiograph, ECG, or Papanicolaou test) or end of the exposure observation window (if not tested).

Results  Included in the chest radiograph, ECG, and Papanicolaou test cohorts of propensity score–matched pairs were 43 532 patients (mean [SD] age, 47.5 [14.4] years; 38.5% female), 245 686 patients (mean [SD] age, 49.9 [13.7] years; 51.1% female), and 29 194 patients (mean [SD] age, 45.5 [27.1] years; 100% female), respectively. At 90 days, chest radiographs in low-risk patients were associated with an additional 0.87 (95% CI, 0.69-1.05) and 1.96 (95% CI, 1.71-2.22) patients having an outpatient pulmonology visit or an abdominal or thoracic computed tomography scan per 100 patients, respectively, and ECGs in low-risk patients were associated with an additional 1.92 (95% CI, 1.82-2.02), 5.49 (95% CI, 5.33-5.65), and 4.46 (95% CI, 4.31-4.61) patients having an outpatient cardiologist visit, a transthoracic echocardiogram, or a cardiac stress test per 100 patients, respectively. At 180 days, Papanicolaou testing in low-risk patients was associated with an additional 1.31 (95% CI, 0.84-1.78), 52.8 (95% CI, 51.9-53.6), and 0.84 (95% CI, 0.66-1.01) patients having an outpatient gynecology visit, a follow-up Papanicolaou test, or colposcopy per 100 patients, respectively.

Conclusions and Relevance  Observed associations in this population-based cohort study suggest that testing in low-risk patients as part of an AHE increases the likelihood of subsequent specialist visits, diagnostic tests, and procedures.

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