Post by the Scribe on Apr 3, 2022 3:33:05 GMT
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We explore “cascades of care” — how a clinician’s desire to be thorough can snowball into a harmful spiral of unnecessary care.
Listen to the full episode below, read the transcript, or scroll down for more information.
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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.
vbidcenter.org/initiatives/low-value-care/
www.choosingwisely.org/
jamanetwork.com/journals/jamainternalmedicine/fullarticle/2786584
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.
jamanetwork.com/journals/jamanetworkopen/fullarticle/2752991
jamanetwork.com/journals/jamainternalmedicine/fullarticle/2735387
The Challenge: Barriers to Stopping Cascades
Even though research shows that the overwhelming majority of physicians are aware of cascades and that they have the potential to harm their patients, cascades (and the low-value care that often spawns them) remain common and difficult to address because of barriers at many levels.
Patient
Patients are rarely aware of what tests are and aren't recommended by evidence
Some patients push for more tests in hopes of confirming or ruling out even unlikely diagnoses
Clinician
Medical culture and training encourages more care and testing
Clinicians don't want to miss anything and some worry about being sued if they do
Clinicians have limited time to explain the tradeoffs of additional tests to patients
Health System
Low-value care is spread throughout the system making it resource-intensive to root out
Reducing expensive hospitalizations and readmissions is seen as a more efficient way to lower costs of care
Fee-for-service payment provides few financial incentives to cut low-value care
Health leaders worry about upsetting clinicians by being too prescriptive with how they should practice
Insurers
Payers could stop paying for some low-value services, but many are wary of making it too difficult to access care that can still be necessary in some cases
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.
www.ajmc.com/view/stopping-the-flood-reducing-harmful-cascades-of-care
www.ncbi.nlm.nih.gov/pmc/articles/PMC4499847/
Education
Most efforts to reduce low-value care to date have focused on educating clinicians on low-value care and its possible consequences. Campaigns like Choosing Wisely have increased awareness and led to modest improvements. There are also efforts to increase patients' awareness so they can make more informed decisions.
onlinelibrary.wiley.com/doi/abs/10.1111/1468-0009.12531
Technology
A small but growing number of hospitals have purchased software that warns clinicians when they're about to order a low-value service. One version of this "clinical decision support" tool serving more than 200,000 providers found clinicians cancelled the low-value order on average 10-13 percent of the time.
www.ajmc.com/view/choosing-wisely-clinical-decision-support-adherence-and-associated-inpatient-outcomes
stansonhealth.com/clinical-decision-support
Payment Reform
Some insurers won't pay for certain low-value services, and many have started paying doctors bonuses to reduce others, as well as holding providers accountable for the total cost of a patient’s care. But these "value-based" arrangements generally make up too small a fraction of a health systems’ revenues and physicians’ compensation to drive significant change.
jamanetwork.com/journals/jama-health-forum/fullarticle/2788514
www.ajmc.com/view/are-valuebased-incentives-driving-behavior-change-to-improve-value
Tradeoffs’ coverage of low-value care is supported, in part, by Arnold Ventures.
Episode Resources (go to original article for hyperlinks)
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)
Episode Credits
Guests:
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!