Journal Article

Curbing Cascades of Care: What They Are and How to Stop Them

Ganguli, Ishani, MD, MPH

2022

Overview

Yet taken together, these cascades can cause substantial harm to patients, including procedural complications, out-of-pocket costs, psychological distress, and stigma from new diagnoses.12 Clinicians, especially those practicing in rural settings, report anxiety, frustration, and wasted time and effort.3,12 There are also financial burdens on the already taxed health care system. Reducing low-value care has been the focus of the Choosing Wisely campaign, through which physician societies create lists of tests and treatments to avoid.13 Practice leaders might also use tactics such as decision support and performance feedback to encourage clinicians to avoid ordering that unnecessary computed tomography (CT) scan or ECG.14 When considering any test (e.g., mammography, screening lung CT), clinicians can be more explicit with patients about the limitations of tests (e.g., false positives) and the possibility of cascades, weighing these and other potential harms against the potential benefits.15 As of April 2021, the 21st Century Cures Act requires that patients have immediate electronic access to their test results; therefore, it is even more important to educate patients in advance that an abnormal result does not always mean something is wrong or warrants more testing. 17 Given these drivers, clinicians would benefit from point-of-care guidance on the risk and management of incidental or borderline findings (e.g., evidence-based recommendations written into result reports that quantify the likelihood of cancer or other outcomes in plain language).3,19,20 Rather than assuming that patients want more testing, we can engage patients in shared decision-making about next steps that take into account their personal risk tolerance.

• Publisher: American Academy of Family Physicians
• Subject: Family Medicine/General Medicine / Health care expenditures / Health risks / Internal Medicine / Medical tests / Primary care / Shared decision making