Dan Gorenstein: A few months ago, I banged up my knee pretty good in a bike accident.

I got an MRI, and my doctor said they saw a growth.

Probably nothing, but just to be sure it wasn’t cancer, he suggested a second more intensive test.

My instinct was, “I guess I should do it. What could it hurt?”

The second MRI came back clean.

But sometimes, doing that extra test can snowball, opening the floodgates to more unnecessary tests — what researchers call a “cascade of care.”

Meredith Niess: Every once in a while, just like you can win the lottery, you can be the person that it finds cancer. But there is a better chance that it’s going to harm you and that it’s going to cost a lot of money.

DG: Today, when doing another test can hurt and the challenges of stopping cascades of care.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, this is Tradeoffs.

*****

DG: Meredith Niess was angry.

It was 2012. She was a primary care resident at a VA clinic in Denver.

And she had just walked out of a visit with a patient we’re going to call Joe.

MN: He had salt and pepper gray hair, medium build. Looked down a lot while we were chatting, but had a really intense eye contact when he would look up. You could tell he was listening. 

DG: Joe should’ve been in an operating room getting a painful hernia near his stomach fixed.

But one of his doctors made Joe get a chest X-ray before his surgery.

That X-ray was the start of Joe’s troubles and why Meredith was so mad.

MN: I knew that that was an unnecessary chest X-ray.

DG: Remember, Joe was having stomach surgery.

Decades of evidence — and common sense — said a chest X-ray wasn’t going to be much use, but it was still common practice.

And when Joe’s came back, it showed a mass inside his lung.

Meredith knew from experience that it was probably nothing — a shadow or a cluster of blood vessels.

Doctors even have a made-up word for this kind of non-finding finding: an “incidentaloma.”

MN: The comparison I always used for folks is if you put your luggage through the X-ray machine and they pull out your bag, you’re not thinking, “Oh my gosh, is there a bomb in my bag?” Most of what they see is, you know, a tube of toothpaste that was sitting in a funny direction, right?

DG: But Joe didn’t know what Meredith knew.

All he knew was that his doctors had found something on his lungs.

And he was scared.

MN: This guy is sweating in his seat when I see him because he’s not thinking about his hernia. It hurts. But who cares if his stomach hurts a little bit because he’s thinking he’s got cancer.

DG: And even though it was probably nothing, now that they’d seen Joe’s incidentaloma, they had to make sure. 

That meant another test, this time a CT scan.

Joe was stuck in what researchers have come to call a “cascade of care” — a string of medical services often spawned by an unnecessary test or procedure.

Meredith tried to reassure Joe that the CT scan would clear everything up.

But he kept firing off questions.

SFX: Am I going to start coughing up blood?

SFX: Are there other symptoms I should look for?

SFX: Do you think it’s cancer?

MN: I couldn’t promise him he didn’t have cancer because he could be that one winner of the terrible lottery who did, so I think he really thought, this was it, this is going to be the end of me.

DG: Four weeks later, Meredith got the results of Joe’s CT scan back.

She opened it up on an ancient VA computer: Joe’s lungs were fine. 

The mass was nothing — just a tube of toothpaste.

But it also showed a new mass, this one on Joe’s adrenal gland right on top of his kidney.

MN: My heart just sank.

DG: Joe had come to the doctor for hernia surgery.

Instead, he’d gotten an unnecessary chest X-ray showing “something.” 

Now he’d just had a CT scan which showed a different “something.”

MN: At this point, it’s like Don Quixote, you know, like I’m chasing imaginary windmills. This doesn’t feel like medicine.

DG: This is what can happen when one of these incidentalomas shows up. The dam usually breaks and everybody — the patient, the doctors, the hospital — are all along for the ride.

Meredith knew standard procedure called for a second CT scan, and she also had a hunch none of this would make any sense to Joe. 

MN: If you go to a friend and say, Yeah, I’m going in for my second CT, I’ve had a chest X-ray and two CT scans, they’d be like, “Oh my God, are you OK, what’s going on?” And here I was the doctor saying, “Don’t worry.” I didn’t think he was going to believe me, and I understood why.

DG: Meredith called Joe. 

It went as well as she expected.

MN: There was never a point where I felt like he understood what was going on. 

DG: The second CT scan finally ended Joe’s cascade.

It was just another benign incidentaloma.

This cascade had set Joe back eight weeks.

Ultimately, it took six months before Joe got that hernia surgery.

Meredith lost touch with Joe, but his experience haunted her.

So a few years later, she wrote about Joe’s case in a medical journal.

She wanted other docs to realize all the physical pain and fear that can come from just one unnecessary test.

MN: You find yourself thinking if they could see this patient right now, they would understand that this test was not worth it.

DG: Doctors are in a bind.

Good medicine often requires multiple steps to arrive at an answer.

What distinguishes a cascade of care is, often, how it starts.

Ishani Ganguli: It’s really driven by the desire to avoid even the slightest risk of missing something potentially life threatening.

DG: Ishani Ganguli is an assistant professor of medicine at Harvard, a primary care doctor and one of the country’s leading researchers on cascades of care. 

She says some cascades start when a test done for a good reason finds something unexpected — like the MRI that showed that growth on my knee after my bike accident.

But most start like Joe’s did,  with a test that should not have happened — what researchers call “low-value services” or “low-value care.”

IG: A low-value service is a service for which there is little to no benefit in that clinical scenario and potential for harm.

DG: For 30 years, doctors and other researchers have found more than 600 procedures, treatments and services unlikely to help people.

Like MRIs for low back pain, prostate cancer screenings for men over 80 and Vitamin D tests.

One study estimated that this type of care costs the U.S. health care system $75 to $100 billion a year. 

For the last decade, the American Board of Internal Medicine Foundation has pushed doctors to reduce low-value care through a major communication campaign called Choosing Wisely.

Ishanni is now taking the next step — investigating what happens after people get this kind of care.

IG: Doctors definitely all understand that tendency for care to snowball. I think there is differing opinion on whether that is just usual care versus something that could have negative effects.

DG: Ishani has been known to use art to make that case. 

Macbeth: By the pricking of my thumbs, something wicked this way comes.

Like araphrasing Macbeth.

IG: I often say it’s a logical progression from the one before, full of sound and fury, often signifying nothing.

Macbeth: …full of sound and fury, signifying nothing.

DG: Or borrowing from the musical group TLC.

TLC: Don’t go chasing waterfalls…

IG: “Don’t Go Chasing Waterfalls” is like the head of a title of one of my slides.

DG: But mostly, she’s done what low-value care researchers have done for the last 30 years to convince the skeptics — she’s used numbers.

IG: We surveyed doctors in 2019 and 99% had experienced cascades in some form.

DG: That same year, she did a deep dive on the financial impact of cascades from one low-value service — an EKG heart test before cataract surgery.

IG: Medicare was spending 10 times the amount on the cascades following those EKGs as they were for the EKGs themselves. We estimated about $35 million per year. So that’s just one example of one service. And you can imagine this extrapolating to a number of other services.

DG: She’s also surveyed doctors asking them how cascades have harmed their patients.

In extreme examples, some reported patients being physically hurt or even dying.

Most said they’d seen their patients suffer psychologically — like Joe’s anxiety thinking he had cancer — as well as financially.

IG: The majority had seen that their patients had been harmed by some form of cascade, and so all of this was really common.

DG: Ishani knows cascades start because physicians don’t want to risk missing something. 

Which makes sense — she feels that pressure herself.

What doesn’t make sense to Ishani is that 41% of docs in one of her surveys said they continued down a cascade even though they didn’t think that next test was needed.

So she asked: Why do it?

The answers hit at the core of what makes a doctor a doctor.

Their training…

IG: They were following the norms of their practice or medical community. It’s just what people do.

DG: Their fear of messing up…

IG: They were concerned about being sued if they missed something.

DG: And their compassion for their patients…

IG: About one-quarter said that their patient had asked for it.

DG: Clearly, once a cascade gets going, it’s hard to slow down.

Ishani found that 62% of the low-value services flagged by Choosing Wisely have a high potential for cascades.

Better to stop them before they ever begin.

When we come back, we hear who’s trying to do that and what’s making it hard to do.

MIDROLL

DG: Welcome back.

Efforts by Ishani Ganguli and others to get more people in health care focused on cascades are still in their infancy. 

Just ask Cheryl Damberg. 

Cheryl Damberg: I have yet to hear a health system leader say “cascade of care.”

DG: Cheryl is a principal senior economist at the RAND Corporation.

She spends a lot of time talking with hospital executives and physician groups about their priorities, and it’s only recently that low-value care has started to come up.

CD: 10 years ago, I would not have heard people talking about low value care in most cases. Today they are talking about it.

DG: Cheryl says that evolution has been driven by researchers better identifying and measuring low-value care and awareness campaigns like Choosing Wisely.

But progress is slow.

Cheryl says low-value care is like salt, sprinkled throughout the health care system.

CD: I look across the list of low-value care services and I think, “Oh my gosh, this is happening in so many different parts of the system,” and it’s very hard to mount attention in all those different places to solve so many different problems.

DG: Scott Weingarten sees firsthand how hard it is for even the most sophisticated, well-resourced hospitals to take this on.

One big challenge: docs and nurses knowing the difference between being thorough and going down a low-value rabbit hole.

Scott says that distinction can change from one patient to the next. 

SW: There isn’t a person on the planet who can remember all the information that’s potentially available to help each and every patient.

DG: Scott’s been working on low-value care longer than almost anyone.

He spent 30 years leading these efforts as a physician and researcher at Cedars-Sinai in Los Angeles.

He’ll be the first to tell you he’s got the passion of a pilgrim.

The doctor laughs at himself for the brash stunt he pulled several years ago at a conference in Chicago with a few hundred chest doctors. 

SW: I did something I probably shouldn’t have done.

DG: Scott was giving a talk to the American College of Chest Physicians about low-value care.

SW: I stood up in front of all of them and said that if anyone without looking at their phones could recite the guideline on when patients should be admitted with pneumonia, I will send them and a significant other anywhere in the United States on me for a week. And I took out my credit card, and I said, “You have 60 seconds to do this.”

No one could do it, and I breathed a sigh of relief.

DG: Scott wasn’t trying to show up all those chest docs.

His point was that if hospitals and physicians were serious about reducing low-value care, they’d need help. 

Over the last decade, around a dozen companies — including one co-founded by Scott — have developed software that health systems can embed in their electronic health records to flag the low-value care for docs and nurses.

SW: We would pop up an alert just making them aware the care that they were about to deliver, the order they had just placed in the electronic health record contradicted available guidelines.

DG: Tools like this are known as “clinical decision supports,” and some big health systems are starting to buy them.

Scott co-founded Stanson Health in 2013 to sell his pop-up software, and it’s now in use by more than 350 hospitals and 200,000 clinicians nationwide.

So how often do docs see these pop-ups and actually cancel that unnecessary test?

SW: 10 to 13 percent of the time.

DG: That’s an average from an internal analysis Stanson ran a couple years ago.

And Scott has mixed feelings about those numbers.

SW: The glass half full is you stick an app in the EHR and you eliminate 10 to 13 percent of low-value care, just like that. Just like that. And that could mean if it’s rolled out across the country, billions and billions of billions of dollars of waste, better quality of care, less anxiety about false positive tests.

DG: It would also go a long way toward stopping cascades like Joe’s before they ever started. 

But that 10 to 13 percent also gnaws at Scott.

SW: The glass half empty, you would ask, why do doctors and other health care providers reject this advice 87 to 90 percent of the time?

DG: Because even with software warning doctors about unnecessary care, the same barriers to change persist that Harvard’s Ishani Ganguli found in her work: a medical culture of more is better, docs fearful of missing something, patients pushing for more.

Tackling those challenges requires serious resources and likely uncomfortable confrontations telling doctors how to do their jobs.

RAND’s Cheryl Damberg says health systems generally haven’t felt it’s worth all the work.

What could change their mind?

In a word: Money.

CD: I think that if payers stop paying for certain low-value care services, it will definitely change the calculation about whether the juice is worth the squeeze.

DG: Hospitals still make most of their money based on how many services they provide, which makes rooting out low-value care a tough sell.

Cheryl says commercial insurers and Medicare have started paying doctors bonuses to reduce specific low-value services and holding providers accountable for the total cost of a patient’s care.

All the experts we talked with agree: No one wants to deliver low value care or receive it.

But the pressure to “just do one more test” remains strong. 

That’s why doctors and patients understanding the next test could hurt matters so much. 

I’m Dan Gorenstein, and this is Tradeoffs. 

Tradeoffs’ coverage of low-value care is supported, in part, by Arnold Ventures.