Cascade Effects of Medical Technology

Center for Costs and Outcomes Research, University of Washington, 146 North Canal Street, Suite 300, Seattle, Washington 98103-8652, USA.
Annual Review of Public Health (Impact Factor: 6.47). 02/2002; 23(1):23-44. DOI: 10.1146/annurev.publhealth.23.092101.134534
Source: PubMed


Cascade effect refers to a process that proceeds in stepwise fashion from an initiating event to a seemingly inevitable conclusion. With regard to medical technology, the term refers to a chain of events initiated by an unnecessary test, an unexpected result, or patient or physician anxiety, which results in ill-advised tests or treatments that may cause avoidable adverse effects and/or morbidity. Examples include discovery of endocrine incidentalomas on head and body scans; irrelevant abnormalities on spinal imaging; tampering with random fluctuations in clinical measures; and unwanted aggressive care at the end of life. Common triggers include failing to understand the likelihood of false-positive results; errors in data interpretation; overestimating benefits or underestimating risks; and low tolerance of ambiguity. Excess capacity and perverse financial incentives may contribute to cascade effects as well. Preventing cascade effects may require better education of physicians and patients; research on the natural history of mild diagnostic abnormalities; achieving optimal capacity in health care systems; and awareness that more is not the same as better.

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Available from: Richard Deyo, Dec 12, 2013
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    • "This would translate in direct savings to the PN on the order of $152,848 USD during the 32-month period (average of $50,00/spine x-rays). Furthermore , the observed 5% decrease in the rate of ordering x-rays also resulted in less patient ionizing radiation exposure [9] [10] [11], and possibly reduced inefficient and potentially inappropriate invasive diagnosis and subsequent treatment [12] [14] [50]. Such issues are likely significance both at the clinical and the population health level [10] [51]. "
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    ABSTRACT: Overuse and misuse of spine x-rays for nonspecific back and neck pain persists among chiropractors. Distribution of educational materials among physicians results in small-to-modest improvements in appropriate care, such as ordering spine x-rays, but little is known about its impact among North American chiropractors. To evaluate the impact of web-based dissemination of a diagnostic imaging guideline on the use of spine x-rays among chiropractors. Quasi-experimental design that used interrupted time series to evaluate the effect of guidelines dissemination on spine x-ray claims by chiropractors enlisted in managed care network in the United States. Consecutive adult patients consulting for complaints of spine disorders. A change in level (the mean number of spine x-ray claims per month immediately after the introduction of the guidelines), change in trend (any differences between preintervention and postintervention slopes), estimation of monthly average intervention effect after the intervention. The imaging guideline was disseminated online in April 2008. Administrative claims data were extracted between January 2006 and December 2010. Segmented regression analysis with autoregressive error was used to estimate the impact of guideline recommendations on the rate of spine x-rays. Sensitivity analysis considered the effect of two additional quality improvement strategies, a policy change and an education intervention. Time series analysis revealed a significant change in the level of spine x-ray ordering weeks after introduction of the guidelines (-0.01; 95% confidence interval=-0.01, -0.002; p=.01), but no change in trend of the regression lines. The monthly mean rate of spine x-rays within 5 days of initial visit per new patient exams decreased by 10 per 1000, a 5.26% relative decrease after guideline dissemination. Controlling for two quality improvement strategies did not change the results. Web-based guideline dissemination was associated with an immediate reduction in spine x-ray claims. Sensitivity analysis suggests our results are robust. This passive strategy is likely cost-effective in a chiropractic network setting.
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    • "Genetic tests can not only be expensive, but may also lead to downstream costs that follow from testing. Such costs include the so-called ‘cascade effect’, defined as a chain of events initiated by an unnecessary test, an unexpected result or patient or physician anxiety, which results in further expensive tests or treatments that may also cause avoidable adverse effects and/or morbidity.5 "
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    ABSTRACT: From a public health perspective, systematic, evidence-based technology assessments and economic evaluations are needed to guide the incorporation of genomics into clinical and public health practice. However, scientific evidence on the effectiveness of predictive genetic tests is difficult to obtain. This review first highlights similarities and differences between traditional screening tests and predictive genetic testing for complex diseases, and goes on to describe frameworks for the evaluation of genetic testing that have been developed in recent years providing some evidence that currently genetic tests are not used in an appropriate way. Nevertheless, evidence-based recommendations are already available for some genomic applications that can reduce morbidity and mortality, and many more are expected to emerge over the next decade. The time is now ripe for the introduction of a range of genetic tests into healthcare practice, but this will require the development of specific health policies, proper public health evaluations, organizational changes within the healthcare systems, capacity building among the healthcare workforce and the education of the public.
    QJM: monthly journal of the Association of Physicians 09/2013; 107(2). DOI:10.1093/qjmed/hct190 · 2.50 Impact Factor
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    • "In the medical realm, diagnosed but asymptomatic individuals are likely to press for follow-up testing, ongoing medical monitoring, and medical management of potential complications associated with Alzheimer's disease [44]. Given the uncertainty around the disease's pathogenesis and treatment mechanisms, the clinical value of such tests is unclear, and these additional costs could strain already-overburdened health systems, making the tradeoffs involved in allocating medical resources even more difficult [32,45]. "
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    ABSTRACT: Research is underway to develop an early medical test for Alzheimer's disease (AD). To evaluate potential demand for such a test, we conducted a cross-sectional telephone survey of 2,678 randomly selected adults across the United States and four European countries. Most surveyed adults (67%) reported that they are "somewhat" or "very likely" to get an early medical test if one becomes available in the future. Interest was higher among those worried about developing AD, those with an immediate blood relative with AD, and those who have served as caregivers for AD patients. Older respondents and those living in Spain and Poland also exhibited greater interest in testing. Knowing AD is a fatal condition did not influence demand for testing, except among those with an immediate blood relative with the disease. Potential demand for early medical testing for AD could be high. A predictive test could not only advance medical research, it could transform political and legal landscapes by creating a large constituency of asymptomatic, diagnosed adults. Key words: Alzheimer's disease, medical testing, predictive testing, medical decision-making, public attitudes, preclinical.
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