Pain, Fear and Waste: The Costs of Unnecessary Care
March 3, 2022
We explore “cascades of care” — how a clinician’s desire to be thorough can snowball into a harmful spiral of unnecessary care.
The Basics: What Is a Cascade of Care?
A cascade of care is a series of medical services often fueled by a clinician’s desire to avoid even the smallest risk of missing a serious condition. They frequently begin with an unexpected result or unnecessary test, sometimes referred to as “low-value care.”
Low-value care (or a low-value service) is a medical service that evidence has shown provides little to no benefit and has the potential to cause harm. The Choosing Wisely campaign has identified more than 600 low-value services, and a recent study found 62% of those services had a high potential for cascades.
Because low-value services have little clinical benefit, the cascades they spawn are more likely to cause a patient harm than lead to a medically useful finding. The harm can be psychological (anxiety over a possible serious diagnosis), financial (out-of-pocket costs for additional services) and physical (complications from invasive procedures). They can also be challenging for clinicians and incredibly costly and wasteful for the health care system.
The Challenge: Barriers to Stopping Cascades
The Opportunities: Ways to Reduce Cascades of Care
Experts generally agree that the most efficient way to stop a cascade is to reduce the low-value care that often spawns them. Given the barriers listed above, researchers believe a combination of tools will likely be required to achieve that goal, some of which are already being used to varying degrees.
Tradeoffs’ coverage of low-value care is supported, in part, by Arnold Ventures.
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Selected Research, Reporting and Resources on Cascades of Care:
Planning for Surgery? You Might Not Need All Those Tests Beforehand. (Jane E. Brody, New York Times, 11/15/2021)
Stopping the Flood: Reducing Harmful Cascades of Care (Pooja Chandrashekar, A. Mark Fendrick and Ishani Ganguli; The American Journal of Managed Care, 4/22/2021)
Cascades of Care After Incidental Findings in a US National Survey of Physicians (Ishani Ganguli, Arabella L. Simpkin, Claire Lupo, Arlene Weissman, Alexander J. Mainor, E. John Orav, Meredith B. Rosenthal, Carrie H. Colla and Thomas D. Sequist; JAMA Network Open; 10/16/2019)
Preoperative Chest X-rays: A Teachable Moment (Meredith Niess and Allan Prochazka, JAMA Internal Medicine, 1/2014)
Why Do Physicians Pursue Cascades of Care After Incidental Findings? A National Survey (Ishani Ganguli, Arabella L. Simpkin, Carrie H. Colla, Arlene Weissman, Alexander J. Mainor, Meredith B. Rosenthal and Thomas D. Sequist; Journal of General Internal Medicine; 7/25/2019)
Selected Research, Reporting and Resources on Low-Value Care:
Low-Value Care at the Actionable Level of Individual Health Systems (Ishani Ganguli, Nancy E. Morden, Ching-Wen Wendy Yang, Maia Crawford and Carrie H. Colla; JAMA Internal Medicine; 9/27/2021)
A 10-Step Program to Successfully Reduce Low-Value Care (Howard Beckman, John Mafi and Beth Bortz; The American Journal of Managed Care; 5/7/2021)
Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System (John N. Mafi, Patricia Godoy-Travieso, Eric Wei, Malvin Anders, Rodolfo Amaya, Carmen A. Carrillo, Jesse L. Berry, Laura Sarff, Lauren Daskivich, Sitaram Vangala, Joseph Ladapo, Emmett Keeler, Cheryl L. Damberg and Catherine Sarkisian; JAMA Internal Medicine; 3/25/2019)
Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program (Aaron L. Schwartz, Michael E. Chernew, Bruce E. Landon and J. Michael McWilliams; JAMA Internal Medicine; 11/2015)
Swimming against the Current — What Might Work to Reduce Low-Value Care? (Carrie H. Colla, NEJM, 7/13/2015)
Meredith Niess, MD, MPH, Clinical Academic Resource Director, University of North Carolina School of Medicine and Novant Health
Ishani Ganguli, MD, MPH, Assistant Professor of Medicine, Harvard Medical School and Brigham and Women’s Hospital
Cheryl Damberg, PhD, MPH, Principal Senior Economist and Director, RAND Center of Excellence on Health System Performance
Scott Weingarten, MD, MPH, Professor of Medicine, Cedars-Sinai Medical Center; Chief Innovation Officer, SCAN Health Plan
The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Epidemic Sound and Blue Dot Sessions.
This episode was reported by Ryan Levi and mixed by Andrew Parrella.
Special thanks to John Mafi.
Additional thanks to:
Rudy Amaya, Malvin Anders, Carrie Colla, Mark Fendrick, Patricia Godoy-Travieso, Ryan Nellis, Catherine Sarkisian, Sam Skootsky, Todd Shannon, the Tradeoffs Advisory Board and our stellar staff!