2019 Update on Medical Overuse: A Review
Authors: Deborah Korenstein
Scott M Wright
Sanket S Dhruva
Daniel J Morgan
Eric R Coon
Journal: JAMA Internal Medicine (2019)
Discipline: CLINICAL MEDICINE
Keywords: Medical overuse; patient harm; medical waste; structured literature review; methodologic quality
Affiliations: Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore., Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore, Maryland., Department of Medicine, School of Medicine, University of California, San Francisco., San Francisco Veterans Affairs Medical Center, San Francisco, California., Department of Pediatrics, University of Utah School of Medicine, Salt Lake City., Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland., Center for Health Policy and Outcomes, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York., Department of Medicine, Weill Cornell Medical College, New York, New York.

Abstract:  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. 

Retracted: No

PubPeer comments:
 Overuse occurs at numerous instances of the health care system. Since 2015, the  Update on Medical Overuse by Daniel Morgan and colleagues offers a systematized overview. Now the Update for 2019 is available. From 1,499 relevant publications published in 2018, the authors selected the 10 most important studies and reviews. The included studies addressed different facets of the topic of overuse: overdiagnosis, overtesting, overtreatment, services to question and methods to reduce overuse. A few highlights from the 2019 Update: The [randomized controlled trial (RCT) of Huang et al.] , which showed that a close determination of procalcitonin in the context of lower respiratory tract infections does not lead to an improvement of the antibiotic prescription behaviour and the clinical course. The [systematic review by Feller et al.](http: doi.org 10.1001 jama.2018.13770), which showed that the therapy of subclinical hypothyroidism with levothyroxine is not associated with positive endpoints such as an improvement in quality of life or cognitive function. The [multicenter RCT by Krag et al.] , which showed that routine stress ulcer prophylaxis with PPI in intensive care patients did not lead to an improvement in the rate of gastrointestinal bleeding. ,