Abstract
For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. Receipt of a given test within 1 week before or after the AWV. Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
Highlights
For healthy adults, routine testing during annual check-ups is considered to be of low value.[1,2,3,4,5] Organizations such as the United States Preventive Services Task Force and the Choosing Wisely campaign[4] advise against routine electrocardiograms (ECGs),[6] urinalyses,[7] and thyrotropin tests[8]
We used national Medicare claims data to estimate the prevalence of routine ECG, urinalysis, and thyrotropin testing performed during annual wellness visits (AWVs), to identify patient, area-level, and visit characteristics associated with receiving these tests, and to measure the prevalence and cost of cascadeattributable laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses that may follow
Patients were more likely to receive any of the 3 routine tests of interest if they were younger, female, White, lived in urban areas, lived in the South or Northeast, or lived in high-income areas
Summary
Routine testing during annual check-ups is considered to be of low value.[1,2,3,4,5] Organizations such as the United States Preventive Services Task Force and the Choosing Wisely campaign[4] advise against routine electrocardiograms (ECGs),[6] urinalyses,[7] and thyrotropin tests[8] (eAppendix 1 in the Supplement). We do not know how often these tests are performed during the Medicare yearly check-up, known as the annual wellness visit (AWV) and introduced in 2011 through the Affordable Care Act.[12]. Routine medical tests during these visits may trigger cascades of further medical services that are of uncertain value and may cause substantial harms to patients and clinicians.[1,13,14,15,16,17] Understanding the prevalence of these tests and their potential cascades would allow payers, policy makers, and clinicians to prioritize and target efforts to mitigate low-value care and its consequences. We used national Medicare claims data to estimate the prevalence of routine ECG, urinalysis, and thyrotropin testing performed during AWVs, to identify patient, area-level, and visit characteristics associated with receiving these tests, and to measure the prevalence and cost of cascadeattributable laboratory tests, imaging tests, procedures, visits, hospitalizations, and new diagnoses that may follow
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