Survey reveals the hidden costs of care cascades

October 29, 2019

Just about any medical test can turn up an incidental finding that leads to a cascade of follow-up tests. For instance, a patient comes in for a routine test to measure their heart activity before cataract surgery and the test picks up what could be an irregularity, which leads to a stress test, which leads to a cardiac catherization, which may reveal that the patient's heart function is just fine and all of the tests, costs and anxiety were for nothing. Anecdotes about these so-called care cascades abound. Through a national survey of physicians, investigators from the Brigham have found that 99 percent of physicians have experienced these cascades of care firsthand and report that such cascades have caused their patients psychological harm, physical harm and financial burden and have caused frustration and anxiety for physicians. The team's findings are published in JAMA Network Open.

"Our findings are both shocking and not surprising at all. Every clinician I have ever spoken to has experienced an incidental finding that led to downstream care that didn't help a patient in the long run," said corresponding author Ishani Ganguli, MD, MPH, a physician researcher in the Division of General Internal Medicine and Primary Care at the Brigham and an assistant professor of Medicine at Harvard Medical School. While in some cases, incidental findings may reveal a clinically important and intervenable discovery, such as an early-stage cancer, more often, subsequent evaluations may find nothing significant.

To determine the national scope of incidental findings and the cascades that can follow, Ganguli and her colleagues conducted a web-based national survey of U.S. internists who are members of the American College of Physicians. The team received 376 completed surveys and found that more than 99 percent of respondents reported experiencing cascades of care. About 90 percent had experienced cascades with clinically important and intervenable outcomes and about 94 percent had experienced cascades with no such outcome. Physicians reported that cascades caused their patients psychological harm, physical harm, and financial burden and personally caused the physicians wasted time and effort, frustration, and anxiety.

The survey also asked physicians about their ideas for possible solutions to the problem of cascades of care. Most physicians believed that having access to guidelines about incidental findings that they could reference while seeing a patient would help limit negative consequences. Many also thought that further educating both physicians and patients about the potential harms of unnecessary medical testing would help both groups.

The authors note that, as with any survey, their study relies on the memory of respondents, which may be influenced by more dramatic outcomes. The study doesn't capture out-of-pocket costs for patients, which is something the researchers are interested in investigating in the future.

"Patients need to know that unexpected findings on medical tests can lead to cascades that can cause patients harm, including out of pocket costs, invasive tests and anxiety," said Ganguli. "We're interested both in quantifying how pervasive a problem cascades of care are as well as solutions to prevent the cascade of unnecessary medical care and harm that may be set off by an incidental finding."
This study was funded by grant 1R01HS023812 from the Agency for Healthcare Research and Quality (AHRQ). Ganguli reported receiving grants from AHRQ and International Business Machines (IBM) Corporation and receiving personal consultancy fees from Haven.

Paper cited: Ganguli, I et al. "Cascades of Care After Incidental Findings in a US National Survey of Physicians" JAMA Network Open DOI: 10.1001/jamanetworkopen.2019.13325

Brigham and Women's Hospital

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