Morgan Daniel J, Dhruva Sanket S, Coon Eric R, Wright Scott M, Korenstein Deborah
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.
JAMA Intern Med. 2019 Nov 1;179(11):1568-1574. doi: 10.1001/jamainternmed.2019.3842.
Medical overuse is an important cause of patient harm and medical waste.
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.
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.
医疗过度使用是患者伤害和医疗浪费的一个重要原因。
通过对2018年发表的高影响力期刊目录进行检查，并对英文文章进行结构化文献综述，确定了与医疗过度使用相关的文章。对文章的方法学质量、临床相关性以及对患者的影响进行了评估。在1499篇候选文章中，839篇涉及医疗过度使用。其中，117篇被认为是最重要的，通过作者共识选出了排名前十的文章。关于医疗过度使用的最重要文章指出了检测方面的问题，包括降钙素原对下呼吸道感染患者的抗生素使用时长没有影响（4.2天对4.3天）；在普通磁共振成像或计算机断层扫描研究中，偶发瘤的出现率为22%至38%；9%死于IV期癌症的女性仍在接受乳房X线筛查；计算机断层扫描肺癌筛查对低风险患者的益处稳定，但伤害率更高。与过度治疗相关的文章报告称，急诊诊所通常过度开具抗生素（在所有就诊中，39%的患者接受了抗生素治疗），亚临床甲状腺功能减退症的治疗对临床结局没有影响。三项研究强调了应受到质疑的服务，包括使用阿片类药物治疗慢性非癌性疼痛（荟萃分析发现没有临床显著益处）、对重症监护病房患者进行应激性溃疡预防（泮托拉唑治疗组死亡率为31.1%，安慰剂组为30.4%）以及对氧水平正常的患者补充氧气（死亡相对风险为1.21；95%置信区间为1.03 - 1.43）。一篇政策文章发现，州医疗责任改革与减少冠状动脉疾病的侵入性检测有关，包括血管造影减少24%。
研究结果表明，许多检测被过度使用，过度治疗很常见，不必要的医疗护理会导致患者伤害。对这些2018年研究结果的综述旨在为希望减少过度使用并改善患者护理的从业者提供信息。
