4 imaging exams called out as examples of unnecessary care

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 - Exam_Order

In its fourth annual update on medical overuse, JAMA Internal Medicine names 10 procedures and practices that are ripe for the curtailing. In the category of “overtesting,” the klieg lights fall on four exams—and all are based in imaging.

The journal posted the study online Oct. 2.

Daniel Morgan, MD, of the University of Maryland and colleagues conducted a structured review of English-language articles archived on PubMed and published in 2016. They also searched the tables of contents from high-impact journals for articles related to medical overuse in adults.

In total, Morgan and colleagues considered 2,252 articles. They whittled this to 1,224 articles addressing the issue at hand, then to the 122 that were most relevant based on originality, methodologic quality and number of patients potentially affected.

Finally the team selected, by consensus, the 10 most influential articles before them.

In the aforementioned overtesting category, the snapshot conclusions of the selected journal articles single out imaging as follows:

  • Transesophageal echocardiography is more sensitive than transthoracic echocardiography for stroke etiology without benefiting patients.
  • Overuse of CT pulmonary-angiography (and underuse of d-dimer blood testing) is common in suspected pulmonary embolism.
  • CT is increasingly performed in patients with respiratory symptoms who have the least to gain.
  • Carotid ultrasonography and carotid revascularization in asymptomatic patients are frequently used for uncertain or inappropriate indications.

In the “overtreatment” category, the authors homed in on interventions for early-stage prostate cancer, oxygen for patients with moderate COPD, surgery for meniscal tears and nutritional interventions for inpatients with malnutrition.

The final category, “methods to reduce overuse,” recommends a practical, shared decision-making tool for low-risk chest pain, along with clinician audit and feedback with peer comparison for antibiotic use.

In their discussion, Morgan et al. comment on some of the themes to emerge from their latest review of the literature on medical overuse.

“First, overreliance on high-technology imaging continues apace,” they write. “The resultant high rates of unnecessary testing lead to overdiagnosis, placing patients at risk for adverse events. Such technology often enters into clinical practice without clinical outcome studies to guide appropriate use, suggesting the need for changes in practice or policy to better protect patients against new technologies that are likely to result in net clinical harm.”

The authors close with an expression of enthusiasm over the continued rapid evolution of the literature on medical overuse.

“Clear understanding of the best approaches to minimize overuse, coupled with ongoing efforts to identify overused services, will be critical for the medical community as we seek to reduce unnecessary care and optimize value,” they write.