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Special Communication | Less Is More

Update on Medical Practices That Should Be Questioned in 2015

Daniel J. Morgan, MD, MS1,2,3; Sanket S. Dhruva, MD4,5; Scott M. Wright, MD6; Deborah Korenstein, MD7
[+] 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 & Policy, Washington, DC
4Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
5Department of Veterans Affairs, West Haven, Connecticut
6Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
7Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Intern Med. 2015;175(12):1960-1964. doi:10.1001/jamainternmed.2015.5614.
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Importance  Overuse of medical care, consisting primarily of overdiagnosis and overtreatment, is a common clinical problem.

Objectives  To identify and highlight articles published in 2014 that are most likely to influence medical overuse, organized into the categories of overdiagnosis, overtreatment, and methods to avoid overuse, and to review these articles and interpret them for their importance to clinical medicine.

Evidence Review  A structured review of English-language articles in PubMed published in 2014 and a review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults.

Findings  We reviewed 910 articles, of which 440 addressed medical overuse. Of these, 104 were deemed most relevant based on the presentation of original data, quality of methods, magnitude of clinical effect, and number of patients potentially affected. The 10 most influential articles were selected by author consensus using the same criteria. Findings included lack of benefit for screening pelvic examinations (positive predictive value <5%), carotid artery screening (no reduction in stroke), and thyroid ultrasonography (15-fold increase in thyroid cancer). The harms of cancer screening included unnecessary surgery and complications. Head computed tomography was an overused diagnostic test (clinically significant findings in 4% [7 of 172] of head computed tomographic scans). Overtreatment included acetaminophen for low back pain, perioperative aspirin use, medications to increase high-density lipoprotein cholesterol level, stenting for renal artery stenosis, and prolonged opioid use after surgery (use >90 days in 3% [1229 of 39 140] of patients).

Conclusions and Relevance  Many common medical practices should be reconsidered. It is anticipated that our review will promote reflection on these 10 articles and lead to questioning of other non–evidence-based practices.

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aLancet, BMJ, JAMA, JAMA Internal Medicine, The New England Journal of Medicine, Annals of Internal Medicine, Medical Care, PLOS Medicine, and Journal of General Internal Medicine.

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