Mar 29th 2017

Medical Testing: One Thing Leads to Another

In an ideal world, every single medical test ordered would be appropriate and necessary. But in our imperfect world, that's pretty much an impossible goal.

In fact, in the worst-case scenario, when a healthcare professional orders an unnecessary test, he or she might end up initiating what's called the "cascade effect." That is, one unnecessary test leads to another (possibly questionable) test, which may lead to a diagnosis and subsequent treatment that may not have been necessary and can be actively harmful to the patient. Think of a snowball rolling down a hill. It starts off as a tiny orb, but by the time it gets to the bottom of the hill, it's huge—and maybe unstoppable.

In a 2002 paper for the Annual Review of Public Health, Richard Deyo noted that one culprit behind the cascade effect is modern technology. Too often, everyone becomes enamored with new medical technology and equates it with better healthcare. But there can be unanticipated "adverse effects and consequences," he warned.

A prime example of medical technology gone awry is the spinal MRI. As Deyo wrote, "Spinal MRI exemplifies the problem of discovering more and more abnormalities with most having no clinical relevance." The test may uncover incidental findings such as degenerative or bulging discs in asymptomatic patients, which can lead to anxiety and even overtreatment, including unnecessary surgery.

Something else to consider is cost. Healthcare costs in the United States have skyrocketed in recent years, and some believe that the cascade effect has contributed to that. For example, consider the cascade effect that often occurs in the critical care setting. The authors of a 2013 editorial for the American Thoracic Society wrote, "In critical care medicine, there is always an easy and natural flow to the 'next-step' therapy, a costly cascade progression. Cascade effects are likely most prominent in cardiology critical care medicine because many mechanical circulatory support devices are placed as 'bridge' therapies." The process of escalation has become reflexive, which can make it hard to slow down or interrupt.

Can You Stop It?

It is possible to avoid triggering the cascade effect, but it requires that clinicians recognize the situation and be prepared to take action to protect their patients from unnecessary harm. They must be very deliberate and thoughtful about every action and consider its possible repercussions.

To break that cascade momentum, clinicians can implement decision points—a kind of time-out, when they stop and check in with patients and their families. This means taking the time to discuss important topics, such as the long-term goals of treatment and the likelihood of success, with the patient. "Decision-point meetings are antidotes to reflexive escalation because they create opportunities for clinician-surrogate deliberation," noted the editorial authors.

Another important factor in breaking that momentum is careful consideration of whether a test is truly warranted, based on standards of evidence-based medicine. You can always consult eviCore's standards for carefully reviewed, evidence-based information that can guide you toward making the best possible decision—and hopefully avoiding triggering the cascade effect. For example, eviCore has created a set of spine imaging guidelines that can provide valuable guidance when considering a spine MRI.

It's never going to be a perfect process, but relying on evidence-based medicine can provide the best scientific information available to help you proceed without inadvertently triggering the cascade effect.