Test Utilization: ‘Cascades of Care’ Cause Wasteful, Unnecessary and Anxiety-Producing Testing

Experts estimate that $200 billion is wasted annually on excessive testing and treatment. The typical dynamic is a chain reaction: Something “comes up” on diagnostic tests or screenings and triggers “cascades” of further testing and treatment. Thus, for example, 52% of radiology and laboratory tests produce incidental findings that result in further screenings and tests. In some cases, further evaluation of these findings may reveal a clinically important and intervenable discovery, such as an early-stage cancer. More often, however, subsequent evaluations find nothing significant.

A new national survey finds that 99% of physicians have experienced cascades of care firsthand and that when they happen their patients experience psychological harm, physical harm and financial burden—in addition to the frustration and anxiety physicians feel themselves. The findings were published in JAMA Network Open (the Study.) 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, the Study recommends.

The Cascade Effect

The term “cascade” was coined to describe a sequence of events set irrevocably into motion after an incidental finding. Cascades are widely prevalent and often inevitable once an incidental finding is discovered. One study found that primary care physicians reported feeling “compelled but frustrated” to pursue the “quagmire” of costly follow-up evaluations for incidental findings that were unlikely to be significant.

The Study found that almost all US internists experienced cascades after incidental findings. Physicians reported that incidental findings frequently prompted telephone calls with patients and repeated tests; most had also seen their patients undergo new invasive tests, emergency department visits, and hospitalizations after an incidental finding. Many reported that they had experienced cascades as patients themselves. For the most part, the physicians reported that the cascades generally led to no clinically important or intervenable outcome for patients.

The Study

The Study was a population-based survey using data from a 44-item cross-sectional, online survey of 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on Jan. 22, 2019, and analysis was performed from March 11 to May 27, 2019.

The Study achieved a 44.7% response rate and weighted responses to be nationally representative. Key findings:

• Almost all respondents—4%—reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%);
• 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, 53.2% of physicians reported that guidelines for follow-up testing did not exist to their knowledge;
• To lessen the negative consequences of cascades, 376 respondents (62.8%) chose accessible guidelines and 44.6% chose decision aids as potential solutions;
• 1% of physicians reported that they wasted time and effort due to cascades as well as frustration (52.5%), and anxiety (45.4%);
• More than two-thirds (68.9%) of all respondents reported experiencing at least one of these harms in the past year;
• Physicians working in rural areas and those who had greater discomfort with uncertainty were more likely to report experiencing at least one of these harms in the past year.

Potential Solutions to the Cascades Problem

One key intervention may be to avoid that initial test whenever possible. One-third of physicians in the Study reported that the initial test in their most recently experienced cascade may not have been clinically appropriate: harms are unlikely to be offset by any benefits from testing in such cases. Physicians themselves also suggested potential options to address cascades:

• 8% believed that accessible guidelines on how to manage incidental findings would help limit the negative consequences of cascades;
• 1% cited patient and clinician education on potential harms from unnecessary medical care as potentially beneficial;
• 6% recommended use of decision aids, i.e., shared decision-making tools; and
• 0% suggested that malpractice reform to alleviate physician liability concerns would help solve the problem.

Fewer physicians thought that patient cost-sharing (18.1%) or value-based payment models (16.2%) would help.

Takeaway

A lot of time, energy and money is wasted when something “comes up” during a screening or test, which more often than not turns out to be nothing. Both patients and doctors needlessly worry, and patients often have to endure additional financial burdens. New treatment guidelines and decision aids for incidental findings, as well as better education, could help alleviate the problem—saving both patients and doctors time and money.