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September 9, 2019

2019 Update on Medical Overuse: A 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, Maryland
  • 3Department of Medicine, School of Medicine, University of California, San Francisco
  • 4San Francisco Veterans Affairs Medical Center, San Francisco, California
  • 5Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
  • 6Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 7Center for Health Policy and Outcomes, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
  • 8Department of Medicine, Weill Cornell Medical College, New York, New York
JAMA Intern Med. 2019;179(11):1568-1574. doi:10.1001/jamainternmed.2019.3842

Importance  Medical overuse is an important cause of patient harm and medical waste.

Observation  This structured literature review of English-language articles supplemented by examination of tables of contents of high-impact journals published in 2018 identified articles related to medical overuse. Articles were appraised for their methodologic quality, clinical relevance, and influence on patients. Of 1499 candidate articles, 839 addressed medical overuse. Of these, 117 were deemed to be most significant, with the 10 highest-ranking articles selected by author consensus. The most important articles on medical overuse identified issues with testing, including that procalcitonin does not affect antibiotic duration in patients with lower respiratory tract infection (4.2 vs 4.3 days); incidentalomas are present in 22% to 38% of common magnetic resonance imaging or computed tomography studies; 9% of women dying of stage IV cancer are still screened with mammography; and computed tomography lung cancer screening offers stable benefit and higher rates of harm for patients at lower risk. Articles related to overtreatment reported that urgent care clinics commonly overprescribe antibiotics (in 39% of all visits, patients received antibiotics) and that treatment of subclinical hypothyroidism had no effect on clinical outcomes. Three studies highlighted services that should be questioned, including using opioids for chronic noncancer pain (meta-analysis found no clinically significant benefit), stress ulcer prophylaxis for intensive care unit patients (mortality, 31.1% with pantoprazole vs 30.4% with placebo), and supplemental oxygen for patients with normal oxygen levels (mortality relative risk, 1.21; 95% CI, 1.03-1.43). A policy article found that state medical liability reform was associated with reduced invasive testing for coronary artery disease, including 24% fewer angiograms.

Conclusions and Relevance  The findings suggest that many tests are overused, overtreatment is common, and unnecessary care can lead to patient harm. This review of these 2018 findings aims to inform practitioners who wish to reduce overuse and improve patient care.

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    1 Comment for this article
    Fear of not being perfect as harmful as fear of malpractice suits as driver of medical overuse
    Edward Volpintesta, MD | Bethel, CT
    There should be little doubt that the threat of a malpractice suit compels most physicians to order tests against their better judgment; but just as importantly, physicians are expected to be perfect and nothing is more harmful to their self-esteem and needless to say their reputation than making a medical error, even if it doesn’t result is a suit.
    The question to be asked is are we expecting too much from physicians? Has our science far outrun our human abilities to deliver the perfect care that we can sometimes deliver but sometimes cannot?

    Edward Volpintesta