Cover: Addressing the Drivers of Medical Test Overuse and Cascades

Addressing the Drivers of Medical Test Overuse and Cascades

User-Centered Design to Improve Patient-Doctor Communication

Published in: The Joint Commission Journal on Quality and Patient Safety, Volume 48, Issue 4, pages 233–240 (April 2022). doi: 10.1016/j.jcjq.2022.01.005

Posted on Jan 27, 2023

by Robert S. Rudin, Nitya Thakore, Kathleen L. Mulligan, Ishani Ganguli


Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise.


Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention.


Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse.


Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

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