US: the ten most unnecessary and overused medical tests

A study by researchers at the University of Maryland School of Medicine highlights some of the most egregious examples of medical overuse in the US. The goal is not to shame anyone, but to make healthcare more effective and efficient, the researchers say.

“Too often, health care practitioners do not rely on the latest evidence and their patients don’t get the best care,” said Daniel Morgan, associate professor of epidemiology and public health and infectious diseases. “Hopefully this study will spread the word about the most overused tests and treatments.”

The research, published in JAMA Internal Medicine, involved analysis of more than 2,200 journal articles published in 2016, to identify the studies that are most relevant to understanding medical overuse or strategies to reduce it.

Morgan and his colleagues selected the ten most influential and relevant articles, relating to different tests. According the research the ten most overused tests and treatments are:

Trans-esophageal echocardiography - an invasive test that is used to look for heart issues that could lead to stroke. Although the test has a reputation for being more sensitive, a recent study found it does not improve outcomes over a simpler test. Because it is an invasive procedure that requires sedation, it poses increased risks for patients compared to other alternatives.

Computed tomography pulmonary angiography - which is used to help diagnose pulmonary embolism, a blockage of a blood vessel in the lung. Researchers found that the test is overused compared to less risky tests. Overuse of the technique is likely to result in delays, higher costs, and patient harm from unnecessary exposure to radiation and contrast dye.

Computed tomography in patients with respiratory symptoms - where there is evidence the test is overused in patients who have non-life-threatening respiratory symptoms. In these cases, CT does not improve patient outcomes and could lead to false positive results. It also poses risks for patients by exposing them to radiation.

Carotid artery ultrasonography and stenting - was performed for uncertain or inappropriate indications, suggesting many of these procedures may be unnecessary. Given the risk of stenting or surgery, this indicates that the test and the procedure are likely both overused.

Aggressive management of prostate cancer following a positive prostate-specific antigen test - study of men who had prostate cancer surgery after being diagnosed through this blood test found the rate of cancer-related death was 1 per cent, with no difference between the groups who had been treated and those who had not been treated. Given that prostate cancer treatments can cause erectile dysfunction and other problems, this suggests that the risks of treatment may outweigh the benefits in many men.

Supplemental oxygen - for patients with the lung illness chronic obstructive pulmonary disease, who had only mild oxygen deficit, did not improve quality of life or lung function.

Surgery for meniscal cartilage tears in the knee - did not improve symptoms, even for patients who had clicking in the knee. Given the fewer risks and lower costs, conservative management and rehabilitation are a more effective strategy.

Nutritional support for medical inpatients - malnutrition may be associated with worse outcomes for hospital patients, but this study found that giving critically ill patients nutritional intervention, generally oral feeding, made no difference in overall death rate or length of stay in the hospital.

Strategies to reduce overuse of antibiotics - this study examined several ways of trying to reduce the number of antibiotic prescriptions. The most effective approach was to show doctors comparisons to their peers who prescribed correctly. In this group, inappropriate prescriptions dropped from nearly 20 percent to less than 4 percent.

Reducing the use of unnecessary cardiac imaging - advanced cardiac imaging for patients with chest pain has more than tripled over the past decade and as a result many low-risk patients may receive tests that could lead to unnecessary hospitalisation and intervention. A study in which doctors and patients shared decision-making over whether or not to test found that this reduced the number of tests.

Jama Internal Medicine: doi:10.1001/jamainternmed.2017.4361