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Less Is More
October 2018

Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments

Author Affiliations
  • 1Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
  • 2Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
  • 3Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
  • 4Division of General Internal Medicine, University of California, San Francisco
  • 5Precision Monitoring to Transform Care Quality Enhancement Research Initiative, San Francisco Veterans Affairs Hospital, San Francisco, California
  • 6New York University School of Medicine, New York, New York
JAMA Intern Med. 2018;178(10):1401-1407. doi:10.1001/jamainternmed.2018.3573
Key Points

Question  What is the scope of negative consequences for patients from overused medical tests and treatments?

Findings  An evidence-based conceptual map of negative consequences of overuse was developed that defined 6 domains: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences in these domains can result directly from overused services and indirectly from downstream services; negative consequences themselves can also lead to additional downstream services.

Meaning  Clarifying the breadth of potential negative consequences of overuse of tests and treatments for patients and the processes that can lead to them can inform efforts to understand and reduce overuse.


Importance  Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described.

Observations  We sought to generate a comprehensive conceptual map documenting the processes through which overused tests and treatments lead to multiple domains of negative consequences for patients. For map development, an iterative consensus process was informed by structured review of the literature on overuse using PubMed and input from a panel of 6 international experts. For map verification, a systematic review was performed of case reports involving overused services, identified through literature review and manual review of relevant article collections. The conceptual map documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. Case reports on overuse confirmed the processes and domains of the conceptual map. Cases also revealed strengths and weaknesses in published communication about overuse: they were dominated by physical harms, with other negative consequences receiving far less attention.

Conclusions and Relevance  This evidence-based conceptual map clarifies the processes by which overused tests and treatments result in negative consequences for patients; it also documents multiple domains of negative consequences experienced by patients. The map will be useful for facilitating comprehensive communication about overuse, estimating harms and costs associated with overused services, and informing health system efforts to reduce overuse.

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    1 Comment for this article
    The wellness industry business model is to overuse tests and brag about it
    Al Lewis, JD | Quizzify
    This article assumes that doctors and patients are the only parties involved in overtesting and overtreatment. The workplace wellness industry would beg to differ. Interactive Health, for example, screens every employee every year for 43 different blood values, and then brags about how "45% of employees have newly discovered conditions." We call this "hyperdiagnosis" -- the hunt for disease by unlicensed, unregulated wellness vendors who then breathlessly announce how many sick people they've found that need more doctor visits.

    A journal article detailing this can be found at https://scholarlycommons.law.case.edu/healthmatrix/vol27/iss1/3/.

    Workplace wellness is truly an example of the observation
    that: "Every cause begins with a movement, becomes a business, and degenerates into a racket," as that article shows.