Doubilet P, Abrams H L
N Engl J Med. 1984 Jan 12;310(2):95-102. doi: 10.1056/NEJM198401123100206.
Despite the considerable literature on the overuse of new medical technologies, little attention has been paid to the biologic and monetary costs that may be incurred by underuse. Percutaneous transluminal angioplasty as a treatment for peripheral vascular disease is an example of an important technology that has been underused. Although angioplasty alone is less costly but also less efficacious than surgery, a strategy that combines the two procedures (angioplasty first, then surgery if angioplasty is unsuccessful or if occlusion recurs) is uniformly superior to surgery alone in patients who have lesions for which angioplasty can be considered. From a nationwide perspective, if 40 per cent of all patients with iliac or femoral disease (or both) requiring intervention were treated with the combined strategy, there would be an estimated savings (as compared with surgery alone) of 352 lives and $82 million, as well as an additional 5006 patent limbs. Despite these advantages, the use of angioplasty during the period under consideration (up to 1980) was limited, possibly because of the mechanism of patient triage and the inertial forces that operate when a therapeutic method that appears effective--even if more complex and hazardous than a newer approach--has been widely applied.
尽管关于新医疗技术过度使用的文献颇多，但对于使用不足可能产生的生物和金钱成本却鲜有关注。经皮腔内血管成形术作为外周血管疾病的一种治疗方法，就是一项未得到充分使用的重要技术的实例。虽然单纯血管成形术成本较低，但疗效也不如手术，对于可考虑采用血管成形术治疗的病变患者，将两种方法结合使用（先进行血管成形术，若血管成形术不成功或出现再闭塞则进行手术）的策略总体上优于单纯手术。从全国范围来看，如果所有需要干预的髂动脉或股动脉疾病（或两者皆有）患者中有40%采用联合策略进行治疗，与单纯手术相比，估计可挽救352条生命，节省8200万美元，还能额外保住5006条有功能的肢体。尽管有这些优势，但在所研究期间（截至1980年）血管成形术的使用仍然有限，这可能是由于患者分类机制以及当一种看似有效的治疗方法（即使比新方法更复杂且危险）被广泛应用时所产生的惯性力量所致。
