• Aimee N Pickering, Xinhua Zhao, Florentina E Sileanu, Elijah Z Lovelace, Liam Rose, Aaron L Schwartz, Allison H Oakes, Jennifer A Hale, Loren J Schleiden, Walid F Gellad, Michael J Fine, Carolyn T Thorpe, and Thomas R Radomski.
• Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. pickeringan@upmc.edu.
• J Gen Intern Med. 2023 Feb 1; 38 (2): 285293285-293.

BackgroundLow-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA).ObjectiveTo examine if the receipt of low-value preoperative testing is associated with greater utilization and costs of potentially related downstream health services in Veterans undergoing low or intermediate-risk surgery.DesignRetrospective cohort study using VHA administrative data from fiscal years 2017-2018 comparing Veterans who underwent low-value preoperative electrocardiogram (EKG) or chest radiograph (CXR) with those who did not.ParticipantsNational cohort of Veterans at low risk of cardiopulmonary disease undergoing low- or intermediate-risk surgery.Main MeasuresDifference in rate of receipt and attributed cost of potential cascade services in Veterans who underwent low-value preoperative testing compared to those who did not KEY RESULTS: Among 635,824 Veterans undergoing low-risk procedures, 7.8% underwent preoperative EKG. Veterans who underwent a preoperative EKG experienced an additional 52.4 (95% CI 47.7-57.2) cascade services per 100 Veterans, resulting in $138.28 (95% CI 126.19-150.37) per Veteran in excess costs. Among 739,005 Veterans undergoing low- or intermediate-risk surgery, 3.9% underwent preoperative CXR. These Veterans experienced an additional 61.9 (95% CI 57.8-66.1) cascade services per 100 Veterans, resulting in $152.08 (95% CI $146.66-157.51) per Veteran in excess costs. For both cohorts, care cascades consisted largely of repeat tests, follow-up imaging, and follow-up visits, with low rates invasive services.ConclusionsAmong a national cohort of Veterans undergoing low- or intermediate-risk surgeries, low-value care cascades following two routine low-value preoperative tests are common, resulting in greater unnecessary care and costs beyond the initial low-value service. These findings may guide de-implementation policies within VHA and other integrated healthcare systems that target those services whose downstream effects are most prevalent and costly.© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.

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