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Review
Less Is More
November 2016

2016 Update on Medical OveruseA Systematic Review

Author Affiliations
  • 1Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
  • 2Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore
  • 3Center for Disease Dynamics, Economics, and Policy (CDDEP), Washington, DC
  • 4Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
  • 5Department of Veterans Affairs West Haven, West Haven, Connecticut
  • 6Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 7Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Intern Med. 2016;176(11):1687-1692. doi:10.1001/jamainternmed.2016.5381
Key Points

Question  Which research articles published in 2015 best illuminate important aspects of the current state of medical overuse?

Findings  Articles on medical overuse point to increased referrals and imaging for headaches, unnecessary admissions for syncope, and early colonoscopies; overtreatment was highlighted by unnecessary use of testosterone, opioids, and diabetes treatment as well as anticoagulation for atrial fibrillation. Reports also suggest a need for reconsideration of current practices for managing Clostridium difficile, low-back pain, and thyroid nodules.

Meaning  The number of articles on overuse nearly doubled from 2014 to 2015, indicating that awareness of overuse is increasing, despite little evidence of improved practice.

Abstract

Importance  Overuse of medical care is an increasingly recognized problem in clinical medicine.

Objective  To identify and highlight original research articles published in 2015 that are most likely to reduce overuse of medical care, organized into 3 categories: overuse of testing, overtreatment, and questionable use of services. The articles were reviewed and interpreted for their importance to clinical medicine.

Evidence Review  A structured review of English-language articles on PubMed published in 2015 and review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults.

Findings  Between January 1, 2015, and December 31, 2015, we reviewed 1445 articles, of which 821 addressed overuse of medical care. Of these, 112 were deemed most relevant based on their originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by consensus using the same criteria. Findings included a doubling of specialty referrals and advanced imaging for simple headache (from 6.7% in 2000 to 13.9% in 2010); unnecessary hospital admission for low-risk syncope, often leading to adverse events; and overly frequent colonoscopy screening for 34% of patients. Overtreatment was common in the following areas: 1 in 4 patients with atrial fibrillation at low risk for thromboembolism received anticoagulation; 94% of testosterone replacement therapy was administered off guideline recommendations; 91% of patients resumed taking opioids after overdose; and 61% of patients with diabetes were treated to potentially harmfully low hemoglobin A1c levels (<7%). Findings also identified medical practices to question, including questionable use of treatment of acute low-back pain with cyclobenzaprine and oxycodone/acetaminophen; of testing for Clostridium difficile with molecular assays; and serial follow-up of benign thyroid nodules.

Conclusions and Relevance  The number of articles on overuse of medical care nearly doubled from 2014 to 2015. The present review promotes reflection on the top 10 articles and may lead to questioning other non–evidence-based practices.

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