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Dr. Meredith Nice feared her patient. She had a painful hernia near her abdomen at the Veterans Affairs Clinic in Denver. Nice, a primary care resident, knew she needed surgery right now. But another doctor had earlier ordered a chest x-ray.
Test results showed mass in the man’s lungs.
“This guy is sweating in his seat, [and] She’s not thinking about her hernia, “Nice said.” She’s thinking she has cancer. “
It was 2012, and the Niess were upset. Although ordering a chest x-ray in such cases was considered routine medical practice, Nice realized something his patient did not understand. Decades of evidence have shown that chest X-rays were unnecessary and that the “mass” was probably a shadow or a cluster of blood vessels. These non-finding findings are so common that doctors call them “incidenalomas.”
Nice also knew that early X-rays would start further tests and further delay the man’s surgery.
In fact, a follow-up CT scan shows a clear lung but reveals another suspicious “something” in the patient’s adrenal glands.
“My heart just sank,” Nice said. “It doesn’t feel like medicine.”
A second CT scan finally cleared her patient for surgery – six months after she arrived for help.
Niess wrote about the lawsuit Clothing Internal Medicine As an example of what researchers call the “cascade of care” – a seemingly unstoppable course of medical examination or procedure.
Cascade can start when a test done for a good reason finds something unexpected. After all, good medicine often requires some sleuthing.
“Low cost care”
The most difficult cascades, however, begin with Nice’s patient, with an unnecessary test – Ishani Ganguly, a primary care physician who is an assistant professor of medicine at Harvard University, and other researchers calling it “low-cost services” or “low-cost care.”
“A low-cost service is a service for which there is little gain in that clinical situation and the potential for loss,” Ganguly said.
Over the past 30 years, doctors and researchers like Ganguly have identified more than 600 methods, treatments and services that are less likely to help patients: tests like MRI for complex lower back pain, prostate cancer screening for men over 80 and regular vitamin D tests.
Research suggests that low-cost care is expensive, with one study estimating that the U.S. healthcare system spends between $ 75 billion and $ 100 billion annually on these services. Ganguly published a study in 2019 showing that the federal government spends 35 35 million a year specifically for care after doctors perform EKG heart tests before cataract surgery – an example of low-cost care.
“Medicare was spending 10 times as much money on cascades to follow those EKGs as they did for the EKGs themselves. This is just one example of a service,” Ganguly said.
Cascades of care are common. According to a study conducted by Ganguly, ninety-nine percent of doctors report experiencing one after a factual investigation. About 9 out of 10 physicians say they have seen a cascade harm a patient, for example, physically or financially.
And yet, in the same study, Ganguly reported that 41% of doctors said they continued Cascade even though they believed the next test was not important due to treatment.
“It’s really driven by the desire to avoid the slightest risk of losing something life-threatening,” Ganguly said. Critics of low-cost care say there is a mentality that comes from medical training that seeks out all the answers, as well as compassion for patients, some of whom have asked for tests.
As the cost of healthcare rises, so does the effort to eradicate low-cost care. In 2012, the American Board of Internal Medicine Foundation began urging physicians to reduce low-cost care through a communication campaign called Chixing Weasley.
An electronic warning for doctors
During that time, about a dozen companies have developed software that health systems can embed in their electronic health records to alert doctors.
“We pop up a warning just to make them aware that they are going to provide care,” explained Scott Wingarten.
Weingarten has worked as a physician at Cedars-Sinai Medical Center in Los Angeles for three decades and has spent years lobbying hospitals across the United States to address the problem.
Weingerten realized that even the most sophisticated, well-resourced hospitals and physicians needed help creating new routines and breaking old habits – such as ordering a chest X-ray with a knee-jerk.
Less than 10% of the healthcare system buys software tools known as “clinical decision support”. But Wengarten, co-founder of Stanson Health and who has since left the company, said an internal analysis showed that electronic alerts had eliminated unnecessary tests in just 10% to 13% of the time.
“When the glass is half full you attach an app to EHR [electronic health record] And you omit 10 to 13 percent of low-cost care, just like “Weingarten said.” It could mean, if it’s rolled out across the country, [we could eliminate] Billions upon billions of dollars are wasted. “
But those 10% to 13% also tickle in Weingarten. “Why do doctors reject this advice 87 to 90 percent of the time?” He asked.
Even with software that warns physicians about unnecessary care, the main obstacles to change remain: the more a medical culture is better, the more doctors are afraid of losing something, the more patients push for something more.
Probably the biggest challenge: Hospitals still make the most of their money based on the number of services provided.
Cheryl Dumberg, a senior economist at RAND Corporation, says money can attract hospitals. “If payers stop paying for some low-cost care services, it will definitely change the calculation of whether this juice is worth squeezing,” he said.
Dumberberg said some commercial insurers and Medicare have started offering bonuses to doctors to reduce certain low-cost services and hold providers accountable for the total cost of patient care. But those agreements are rare.
No one wants to pay for or accept low-cost care. But in American medicine, the pressure to “just do one more test” is strong.
Produced this story TradeoffA podcast explores our confusing, expensive, and often anti-healthcare system.