Morgan Daniel J, Dhruva Sanket S, Wright Scott M, Korenstein Deborah
Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore2Department of Hospital Epidemiology, Veterans Affairs Maryland Health Care System, Baltimore3Center for Disease Dynamics, Economics, and Policy (CDDEP), Washington, DC.
Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut5Department of Veterans Affairs West Haven, West Haven, Connecticut.
JAMA Intern Med. 2016 Nov 1;176(11):1687-1692. doi: 10.1001/jamainternmed.2016.5381.
Overuse of medical care is an increasingly recognized problem in clinical medicine.
To identify and highlight original research articles published in 2015 that are most likely to reduce overuse of medical care, organized into 3 categories: overuse of testing, overtreatment, and questionable use of services. The articles were reviewed and interpreted for their importance to clinical medicine.
A structured review of English-language articles on PubMed published in 2015 and review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults.
Between January 1, 2015, and December 31, 2015, we reviewed 1445 articles, of which 821 addressed overuse of medical care. Of these, 112 were deemed most relevant based on their originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by consensus using the same criteria. Findings included a doubling of specialty referrals and advanced imaging for simple headache (from 6.7% in 2000 to 13.9% in 2010); unnecessary hospital admission for low-risk syncope, often leading to adverse events; and overly frequent colonoscopy screening for 34% of patients. Overtreatment was common in the following areas: 1 in 4 patients with atrial fibrillation at low risk for thromboembolism received anticoagulation; 94% of testosterone replacement therapy was administered off guideline recommendations; 91% of patients resumed taking opioids after overdose; and 61% of patients with diabetes were treated to potentially harmfully low hemoglobin A1c levels (<7%). Findings also identified medical practices to question, including questionable use of treatment of acute low-back pain with cyclobenzaprine and oxycodone/acetaminophen; of testing for Clostridium difficile with molecular assays; and serial follow-up of benign thyroid nodules.
The number of articles on overuse of medical care nearly doubled from 2014 to 2015. The present review promotes reflection on the top 10 articles and may lead to questioning other non-evidence-based practices.
医疗服务过度使用是临床医学中一个日益受到关注的问题。
识别并重点介绍2015年发表的、最有可能减少医疗服务过度使用的原创研究文章，这些文章分为三类：检查过度使用、过度治疗以及服务使用存疑。对这些文章的重要性进行了评审和解读，以评估其对临床医学的意义。
对2015年发表在PubMed上的英文文章进行结构化综述，并查阅相关期刊的目录，以确定与成人医疗过度使用相关的潜在文章。
在2015年1月1日至12月31日期间，我们共评审了1445篇文章，其中821篇涉及医疗服务过度使用问题。基于其原创性、方法学质量以及可能受影响的患者数量，其中112篇被认为最为相关。通过共识，使用相同标准选出了10篇最具影响力的文章。研究结果包括：单纯性头痛的专科转诊和高级影像学检查增加了一倍（从2000年的6.7%增至2010年的13.9%）；低风险晕厥患者不必要的住院治疗，常导致不良事件；34%的患者结肠镜检查筛查过于频繁。过度治疗在以下领域较为常见：四分之一的低血栓栓塞风险房颤患者接受了抗凝治疗；94%的睾酮替代疗法未遵循指南建议；91%的患者在过量用药后恢复服用阿片类药物；61%的糖尿病患者被治疗至血红蛋白A1c水平低至可能有害的程度（<7%）。研究结果还确定了一些值得质疑的医疗行为，包括使用环苯扎林和羟考酮/对乙酰氨基酚治疗急性腰痛、使用分子检测法检测艰难梭菌以及对良性甲状腺结节进行系列随访。
从2014年到2015年，关于医疗服务过度使用的文章数量几乎翻了一番。本综述促使人们对这10篇顶级文章进行反思，并可能引发对其他非循证医疗行为的质疑。
