More on Budgeting

'Care cascades,' or unwarranted tests, show hidden costs

Successive rounds of unnecessary testing can cause physical and psychological harm to patients and waste an estimated $200 billion annually.

Jeff Lagasse, Associate Editor

Just about any medical test can turn up an incidental finding that leads to a cascade of follow-up tests. A sample scenario: A patient comes in for a routine test to measure his 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 catheterization, 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% 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.


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While in some cases incidental findings may reveal a clinically important and intervenable discovery, such as an early-stage cancer, it's more often that subsequent evaluations find nothing significant.

To determine the national scope of incidental findings and the cascades that can follow, the authors 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% of respondents reported experiencing cascades of care.

About 90% had experienced cascades with clinically important and intervenable outcomes and about 94% 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.


According to a 2017 Kaiser Health News report, some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care also can harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year.

Digging down into specific treatments and procedures found that for breast cancer specifically, a three-week treatment program is often just as effective as a more costly six-week program. While the shorter treatment may increase the risk of side effects, patients often aren't told about their options, and some physicians aren't aware there are any, or don't consider that the shorter treatment may be more appropriate in certain cases.

Twitter: @JELagasse

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