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Promoting Patient Clinician Conversations to Reduce Cascades of Care


Top view of a mircoscope.

By Kathleen L. Mulligan; Ishani Ganguli MD, MPH; and Robert S. Rudin PhD, SM

A cascade of care is a seemingly uncontrollable sequence of medical services that is driven by the desire to avoid even the smallest risk of a bad outcome.

Cascades prompted by low-value medical tests or incidental findings (on any test) are both common and consequential, often having limited clinical value and potential for harm. We set out to identify what drives cascades and to design an intervention to mitigate them. 

We learned through interviews that most patients did not see medical tests as having potential downsides, such as false positives and incidental findings. They also assumed more tests were better. Meanwhile, doctors were often unsure how to talk about test ordering decisions and incidental findings with patients. We therefore focused on promoting productive patient–clinician conversations about medical tests. 

We hoped that improving shared decision-making discussions might both decrease low-value medical test orders and, in turn, limit downstream services that are of little benefit to patients. To accomplish these goals, we used an iterative, user-centered design process to develop an intervention that includes:

  • patient pre-visit education materials
  • physician reference materials
  • physician peer comparison

Our efforts are detailed in the article, “Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient–Doctor Communication,” from the April 2022 issue of The Joint Commission Journal on Quality and Patient Safety.

Pre-visit Education Materials
Our patient pre-visit education materials include a website, video, and interactive quiz that each focus on three key points to promote what we call patient “medical test literacy”:

  1. medical tests are one of several tools in a doctor’s toolbox
  2. medical tests have both benefits and downsides
  3. patients can talk with their doctors and ask them questions about the purpose of medical tests and alternatives 

These materials arose from conversations in which physicians shared that they have limited time during visits to explain the pros and cons of medical tests and patients told us that they were usually offered medical tests without discussion of possible incidental findings, false positives, or cascades. 
Priming patients with medical test education before visits may leave less need for doctors to explain and normalize not ordering a test if it isn’t needed. These materials may also empower patients to engage in conversations about which tests to order and set expectations about how medical tests may impact what happens next. 

Clinician Reference Materials
We also developed clinician reference materials on medical test interpretation and incidental findings in response to physician feedback that they are sometimes puzzled by how to discuss or follow up incidental findings with patients. Our reference materials outline best practices and include frameworks, scripted language and guidelines to facilitate medical testing decisions, result interpretation, and management of incidental findings. 

Peer Comparison
When some clinicians shared beliefs that they already follow best practices for test ordering and discussing test results with patients—suggesting that clinician reference materials alone might be insufficient to change behavior—we added a peer comparison component to the intervention. The peer comparison nudges clinicians to reflect on their test-ordering habits and review the supplied reference materials by showing them how their rates of ordering potentially low-value tests compare to those of their peers. 

We are currently testing our multi-component intervention in a randomized controlled trial to assess its impact on patient–doctor conversations. Though our intervention does not address all drivers of cascades, it represents an early attempt to address a complex problem with high stakes for patients, clinicians, and the healthcare system. 

Kathleen L. Mulligan is a Research Assistant in the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital (BWH) in Boston. Ishani Ganguli, MD, MPH, is a Clinical Investigator in the Division of General Internal Medicine and Primary Care at BWH and an Assistant Professor at Harvard Medicine School in Boston. Robert S. Rudin, PhD, SM, is a Senior Information Scientist in the Health Care Division at RAND Corporation in Boston and on staff in the Division of General Internal Medicine and Primary Care at BWH.