Cascades of Care After Incidental Findings in a US National Survey of Physicians
Cascades of Care After Incidental Findings in a US National Survey of Physicians
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DOI：
10.1001/jamanetworkopen.2019.13325
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发表时间：
2019-10-01
影响因子：
13.8
通讯作者：
Sequist, Thomas D.
中科院分区：
文献类型：
--
作者：
Ganguli, Ishani;Simpkin, Arabella L.;Sequist, Thomas D.
重要性筛查和诊断测试的偶然发现是常见的，并可能提示级联的测试和治疗是不确定的价值。迄今为止，还没有研究检查了医生的看法和经验，这些级联nationals. ObjectiveTo估计的国家频率和后果的级联护理后，偶然发现，使用一项全国性的调查，美国physics.DESIGN，SETTING，和参与者人口为基础的调查研究，使用的数据从一个44项横截面，在线调查991执业美国内科医生在一个研究小组代表美国医师学会国家会员。该调查于2019年1月22日通过电子邮件发送给小组成员，并于2019年3月11日至5月27日进行分析。主要结果和指标医生报告既往级联经验，他们最近经历的级联特征，以及对潜在干预措施的感知，以限制级联的负面后果。结果本研究的应答率为44.7（376份已完成的调查）并对答复进行加权，使其具有全国代表性。受访者的平均（SE）年龄为43.4（0.7）岁，60.4%的受访者为男性。几乎所有受访者（99.4%;百分比加权）报告经历级联，包括具有临床重要性和可干预结局的级联（90.9%）和无此类结局的级联（94.4%）。医生报告级联造成他们的病人的心理伤害（68.4%），身体伤害（15.6%）和经济负担（57.5%），并造成医生个人浪费时间和精力（69.1%），沮丧（52.5%）和焦虑（45.4%）。当被问及他们最近的级联反应时，371名受访者中有33.7%的人报告说，该测试揭示了偶然发现可能在临床上不合适。在最近的级联中，医生报告未遵循随访检测指南（8.1%）或据他们所知不存在（53.2%）。为了减轻负面后果的级联，62.8%的376名受访者选择了方便的指南和44.6%的选择决策援助作为潜在的solutions.Conclusions和相关性-调查结果表明，几乎所有的受访者都经历了级联后，偶然的发现，并没有导致临床有意义的结果，但对患者和自己造成伤害。政策制定者和卫生保健领导者应该解决偶然发现后的级联反应，作为提高卫生保健价值和减少医生倦怠的努力的一部分。
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.