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Some medical tests, such as MRIs done early for uncomplicated low back pain and routine vitamin D tests “just to be thorough,” are considered “low-value care” and can lead to further testing that can cost patients thousands of dollars.
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Some medical tests, such as MRIs done early for uncomplicated low back pain and routine vitamin D tests “just to be thorough,” are considered “low-value care” and can lead to further testing that can cost patients thousands of dollars.
ER Productions Limited/Getty Images
Dr. Meredith Niess saw her patient was scared. He’d come to the Veterans Affairs clinic in Denver with a painful hernia near his stomach. Niess, a primary care resident, knew he needed surgery right away. But another doctor had already ordered a chest X-ray instead.
The test results revealed a mass in the man’s lung.
“This guy is sweating in his seat, [and] he’s not thinking about his hernia,” Niess said. “He’s thinking he’s got cancer.”
It was 2012, and Niess was upset. Though ordering a chest X-ray in a case like this was considered routine medical practice, Niess understood something her patient didn’t. Decades of evidence showed the chest X-ray was unnecessary and the “mass” was probably a shadow or a cluster of blood vessels. These non-finding findings are so common that doctors have dubbed them “incidentalomas.”
Niess also knew the initial X-ray would trigger more tests and delay the man’s surgery further.
In fact, a follow-up CT scan showed a clean lung but picked up another suspicious “something” in the patient’s adrenal gland.
“My heart just sank,” Niess said. “This doesn’t feel like medicine.”
A second CT scan finally cleared her patient for surgery — six months after he’d come for help.
Niess wrote about the case in JAMA Internal Medicine as an example of what researchers call a “cascade of care” — a seemingly unstoppable series of medical tests or procedures.
Cascades can begin when a test done for a good reason finds something unexpected. After all, good medicine often requires some sleuthing.
“Low-value care”
The most troubling cascades, though, start like Niess’ patient’s, with an unnecessary test — what Ishani Ganguli, a primary care physician who is an assistant professor of medicine at Harvard University, and other researchers, call “low-value services” or “low-value care.”
“A low-value service is a service for which there is little to no benefit in that clinical scenario, and potential for harm,” Ganguli said.
Over the past 30 years, doctors and researchers like Ganguli have flagged more than 600 procedures, treatments and services that are unlikely to help patients: Tests like MRIs done early for uncomplicated low back pain, prostate cancer screenings for men over 80 and routine vitamin D tests.
Research suggests low-value care is costly, with one study estimating that the U.S. health care system spends $75 billion to $100 billion annually on these services. Ganguli published a paper in 2019 that found the federal government
