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Special Communication
Less Is More
December 3, 2018

2018 Update on Medical Overuse

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
  • 3Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
  • 4Department of Veterans Affairs West Haven, West Haven, Connecticut
  • 5Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
  • 6Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 7Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Intern Med. 2019;179(2):240-246. doi:10.1001/jamainternmed.2018.5748

Importance  Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse.

Observations  A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits).

Conclusions and Relevance  Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.

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