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Cited by 187Healthcare cost, quality, practicesRadiology practices and educationClinical Laboratory Practices and Quality Control

Cascades of Care After Incidental Findings in a US National Survey of Physicians

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Ganguli, Ishani, Simpkin, Arabella L., Lupo, Claire, Weissman, Arlene, Mainor, Alexander J., Orav, E. John, Rosenthal, Meredith B., Colla, Carrie H. +1 more·2019·JAMA Network Open
DOI 10.1001/jamanetworkopen.2019.13325PMC PMC6806665
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Abstract

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

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  • When AI-ECG is applied to a routine ECG obtained for another purpose, the output functions as an incidental risk signal and may trigger cascades of follow-up testing with uncertain net benefit.

    “When AI-ECG is applied to a routine ECG obtained for another purpose, the output functions as an incidental risk signal and may trigger cascades of follow-up testing with uncertain net benefit.”

    From AI-ECG for Echocardiography Triage in Structural Heart Disease: Evidence, Implementation, and Future Directions (2026) · cites this paper as [63]

    The Introduction (page not provided) says incidental findings can trigger follow-up of uncertain value and gives an ECG anomaly leading to a stress test and catheterization as an example. The paper does not address AI-ECG outputs or establish that applying AI to an ECG obtained for another purpose produces an incidental risk signal. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Fairness is not only a model-performance issue; it is also shaped by ECG acquisition quality, care setting, access to confirmatory echocardiography, and linkage to disease-specific treatment.

    “Fairness is not only a model-performance issue; it is also shaped by ECG acquisition quality, care setting, access to confirmatory echocardiography, and linkage to disease-specific treatment.”

    From AI-ECG for Echocardiography Triage in Structural Heart Disease: Evidence, Implementation, and Future Directions (2026) · cites this paper as [63]

    The Introduction (page unavailable) discusses incidental findings that trigger further testing and treatment, including an ECG anomaly followed by a stress test and catheterization. Neither that passage nor the searched passages address fairness, ECG acquisition quality, care setting, access to confirmatory echocardiography, or linkage to disease-specific treatment. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Uneven performance in gatekeeper use could translate into unequal access to imaging.

    “This issue is especially important for gatekeeper use, where uneven performance could translate into unequal access to imaging.”

    From AI-ECG for Echocardiography Triage in Structural Heart Disease: Evidence, Implementation, and Future Directions (2026) · cites this paper as [63]

    The Introduction discusses incidental findings that trigger further testing, and the Discussion considers how guidelines might affect follow-up decisions. Neither passage addresses gatekeeper performance or unequal access to imaging; searches for those concepts found no supporting passage in our copy. No page numbers were provided for these passages. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

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Authors
Ganguli, I., Simpkin, A. L., Lupo, C., Weissman, A., Mainor, A. J., Orav, E. J., Rosenthal, M. B., Colla, C. H., & Sequist, T. D.
Affiliations
  • Brigham and Women's Hospital (US)
  • Harvard University (US)
  • American College of Physicians (US)
  • Dartmouth Institute for Health Policy and Clinical Practice (US)
Corresponding author
Ganguli, Ishani
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2019-10-16
Volume
2
Issue
10
Pages
e1913325
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2019.13325
PMC
PMC6806665
OpenAlex
W2980539853
Cited by
187
References
0
Citations by year
2026: 28 · 2025: 26 · 2024: 28 · 2023: 19 · 2022: 32 · 2021: 29 · 2020: 23 · 2019: 2
FWCI
29.31
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
Agency for Healthcare Research and Quality (R01HS023812)
Topics
  • Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiology practices and education
  • Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
Keywords
incidental finding, overuse of diagnostic testing, physician perceptions, internists, psychological harm, financial burden, decision aids, physician burnout, health care value, unnecessary interventions, screening test, diagnostic testing, patient harm, physician anxiety, physician frustration, health care costs, quality of care
MeSH terms
Occupational Stress, Adult, Cross-Sectional Studies, Decision Support Techniques, Female, Patient Care, Humans, Internal Medicine, Male, Middle Aged, Practice Patterns, Physicians', Physicians, Surveys and Questionnaires, Practice Guidelines as Topic, Unnecessary Procedures, Guideline Adherence, Incidental Findings

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