Here are some common questions about overuse:
- What is overuse?
- How do tests and treatments get overused?
- How can overuse affect me?
- How do we know overuse is a problem?
- Isn’t undertreatment the most important problem in the American health care system?
- What can I do about overuse?
- Where can I learn more?
What is overuse?
Overuse is a catchall term for medical tests, treatments, and other services that patients don’t need or don’t want.
- Overuse occurs when a patient is hospitalized unnecessarily, or receives a test, treatment, drug, or procedure that is unnecessary, ineffective, or unwanted.
- “Unnecessary” means that a particular patient is very unlikely to benefit from the treatment because they don’t have the disease or symptom it’s intended to diagnose or treat, or because the possible harms of treatment outweigh the possible benefits.
- “Ineffective” means that the treatment has been shown to be no more effective than no treatment or a placebo (sugar pill or sham surgery).
- “Unwanted” means that the patient, if fully informed, would choose another testing or treatment option.
- Estimates of the money wasted on overuse each year range from around $200 billion to over $800 billion – between 10 percent and 30 percent of US health care spending.
- Overdiagnosis is a related problem, where patients are diagnosed with conditions that were unlikely to cause symptoms or shorten the patient’s life. With increased use of screening tests and highly sensitive imaging technologies such as MRI and CT scans, more conditions are being diagnosed based on anatomical abnormalities and treated as actual disease. This is most common for cancers like breast, prostate, and thyroid cancer, many cases of which are slow-growing and not harmful, but which many patients and doctors are uncomfortable leaving untreated. Overdiagnosis is also common for some mental health conditions, such as ADHD in children.
How do tests, treatments, and other medical procedures get overused?
There are many causes of overuse, but one of the most important drivers is uncertainty. Uncertainty is common in medicine, often because insufficient scientific evidence exists to indicate what option is best for patients, or because the patient’s condition is difficult to diagnose with certainty. Many incentives in our medical system (including financial and legal pressures) make physicians feel the safest course is to resolve uncertainty by giving patients more tests, or more invasive treatment, rather than less. Some causes of overuse include:
- Indication creep. When drugs and treatments are developed, they’re often intended to help very sick patients – and for those patients, the treatment can be very effective. Then the treatments are used on less- and less-sick people (for instance, when a drug manufacturer tries to expand the market for its product). The broadening of possible uses for a treatment, or “indications,” is sometimes called “indication creep.”
- Examples: Statins (cholesterol-lowering drugs) are an effective way to reduce the risk of a heart attack in people with serious heart disease. When the drugs are prescribed to people without prior heart disease (as they most commonly are), those people are unlikely to benefit. Stents for patients who are having a heart attack have been shown to be an effective way to prevent them from dying. Stents for patients who have asymptomatic heart disease or stable disease do not reduce the risk of death or of a future heart attack.
- Preference misdiagnosis. Many surgeries are elective, which means there are multiple ways to treat the disease or relieve its symptoms. However, patients don’t always know about all of their options, and sometimes doctors present one treatment or another as the only or clearly best option without giving patients the opportunity to consider their own preferences. Even if patients meet the legal standard of “informed consent,” often they are not fully informed, and therefore they may not understand all of the other reasonable treatment options and the possible benefits and harms of each. “Preference misdiagnosis” refers to cases where a clinician assumes he or she knows a patient’s preference for treatment or testing, but the patient would have chosen another option with better information and clear communication with the doctor. Often, preference misdiagnosis can be avoided by using shared decision making or patient decision aids. (See a sample decision aid here.)
- Examples: Hip or knee replacement surgery vs. physical therapy for osteoarthritis; prostatectomy vs. radiation vs. watchful waiting for early prostate cancer; lumpectomy vs. mastectomy for early breast cancer.
- Supply-sensitive treatment. Patients who live in areas of the country with more medical resources, such as doctors, hospital beds, and CT scanners, receive more imaging tests, time in the hospital, more procedures, and more visits with doctors compared with patients who live in areas with fewer medical resources. Even with all that extra treatment, the health of patients who live in resource-rich areas often is no better. Researchers at Dartmouth and elsewhere argue that variation in the volume of care patients receive in different regions arises because of differences in the medical resources available. Physicians may be unconsciously influenced by the availability of resources such as CT scanners when they make many discretionary decisions about how to care for patients. For example, if they’re not sure whether a patient needs to be hospitalized, or needs an imaging test, but the hospital bed or CT scanner is freely available, the patient ends up getting hospitalized or scanned. Often, extra medical care makes little or no difference in how well the patient does. This is especially problematic for patients at the end of life, when most patients say they do not want to spend unnecessary time in the hospital or ICU. How much time people spend in the hospital at the end of life has less to do with what they want than where they live and the supply of hospital beds and ICU units.
- Examples: Patients with nonspecific chest pain are more or less likely to be admitted to the hospital depending on the number of hospital beds available where they live. The number of times a patient sees a physician, and the number of different physicians he or she sees, in the last few months of life depends in part on the supply of physicians in the area. How frequently patients with chronic illness are told to return for checkups depends in part on the local supply of doctors in that specialty.
- Fear of litigation. Many physicians express worry about getting sued for missing a diagnosis or not giving a patient a particular treatment. Many believe that ordering an unnecessary test “just to be sure,” making a recommendation for further testing, or giving a patient a treatment, even one that is unlikely to help, will prevent such a lawsuit. This has become known as practicing “defensive medicine.” However, these worries may be unfounded. Some research suggests that physicians are no more likely to get sued when they avoid ordering unnecessary tests. Moreover, doctors prescribing unnecessary and potentially harmful treatments in order to protect themselves from litigation are putting their patients at needless risk of being harmed, by a medical error or hospital-acquired infection. However, despite physicians’ duty to avoid defensive medicine, the fear remains an important driver of overuse.
- Example: Head CT for a child with no evidence of a head injury after a fall; extensive pre-operative testing.
- Patient demand and patient satisfaction scores. Some doctors believe that patients want more treatment, and feel more taken care of when they get a prescription or impressive-sounding test. Sometimes those worries can be magnified when physicians know their employer pays attention to the doctor’s scores on patient satisfaction surveys.
- Example: Physicians often prescribe unnecessary antibiotics for upper respiratory infections (colds), which are usually caused by viruses, when patients ask for the drug.
- Financial pressure. Hospitals and physicians often have financial incentives to give patients more tests and treatments than are necessary. Most physicians work on a fee-for-service basis, and get paid more for doing more procedures, ordering more tests, and choosing more invasive treatments. Hospitals face similar incentives: highly-reimbursed procedures like CT scans and cardiac catheterizations can make the difference between a financially successful hospital and one in serious trouble, especially when the hospital has gone into debt to expand its capacity or purchase expensive medical equipment. Such financial considerations contribute to the amount of unnecessary treatment patients receive.
How can overuse affect me?
- Risk of harm, medical error, and side effects. All medical treatments pose some risk of harm, even if clinicians do everything right. For example, CT scans use radiation to create images of structures inside the body, the more radiation a person receives, the more likely they are to develop cancer in the future. CT scans can also mislead doctors into believing a patient has a condition that is not there, or thinking the patient does not have a condition that in fact needs to be treated. When a patient undergoes surgery, he or she is at risk of suffering a complication, such as an infection or bleeding, which can be fatal. Those risks stay the same, whether or not the surgery was necessary. Indeed, for all treatments and tests, the potential for harm remains the same, whether or not the treatment or test is likely to be beneficial. It’s the nature of most treatments that you are exposed to the possible harms even when you can’t get any benefit, meaning the hundreds of thousands of unnecessary CT scans performed each year cause substantial harm – thousands of excess cases of cancer over patients’ lifetimes. In addition to serious complications, most treatments have common, less serious side effects. Antibiotics often cause diarrhea; statins can cause muscle pain and memory problems; inserting an IV can be painful. None of those is likely to kill you, but they’re unpleasant and may not be worth it if the treatment isn’t doing any good.
- Medical errors. Additional harm can come from medical errors and other avoidable problems, such as falls and hospital-acquired infections. Those risks are substantial. In 1999 the Institute of Medicine published a report called To Err is Human, which estimated that around 100,000 people were killed each year by medical errors. More recent estimates suggest that the toll from avoidable harm is much higher – perhaps as many as 400,000 deaths each year.
- Preference misdiagnosis. When you are considering treatment or getting screened for many conditions, your doctor might not present all the reasonable choices. You might end up getting a treatment that you wouldn’t have wanted if you’d known all of the relevant information, and that could mean unnecessary surgical pain and recovery time, overdiagnosis from unwanted screening tests, and the risk of serious complications from unwanted treatment.
- Painful, unpleasant end-of-life care. Many patients at the end of life receive very intense treatment in the hope of extending their lives. However, that treatment is often futile, and it can be painful, undignified, and expensive. Patients and clinicians are often reluctant to have frank conversations about what patients want at the end of life, but those conversations are crucial to avoid causing unnecessary suffering for dying patients.
- Overdiagnosis. Overdiagnosis of such conditions as breast cancer, prostate cancer, ADHD, and pulmonary embolism (a blood clot in the lungs) can lead to harm from unnecessary follow-up testing and treatment, plus substantial unnecessary anxiety, emotional distress, and disruption to your life from dealing with the condition.
- Financial harm. High medical spending can affect you in many ways. If you don’t have insurance (or your insurance doesn’t cover all the treatment you get), you could face large medical bills. Medical expenses are the most common cause of personal bankruptcy in the United States. Even if you have good insurance, you’re not getting it for free: people pay for insurance in lower wages and higher taxes, and high health care spending growth has been an important contributor to stagnating middle-class wages in recent decades. High medical spending can also harm communities, and reduce the availability of needed public services. For example, the town of China, Maine faced serious financial problems because of its spending on employees’ health insurance. Detroit faced similar problems in paying for retiree health benefits, which contributed to the city’s bankruptcy.
How do we know overtreatment is a problem?
- Randomized trials. Many common medical treatments have been tested in randomized controlled trials and found to be ineffective. (Randomized controlled trials are considered the gold standard of medical evidence.) Those trials include:
- Sham surgery studies (showing, for example, that two kinds of arthroscopic knee surgery are no more effective than fake surgery);
- Randomized trials of screening for ovarian cancer (showing screening didn’t help patients live longer than they would have if the cancer was detected when it started to cause symptoms);
- Tests of patient decision aids (showing that many people choose less-intense treatments, or sometimes no treatment, for some conditions when they’re better informed); and
- Comparative effectiveness trials and meta-analyses showing that a newer, more expensive, or riskier drug or treatment is no better than the older, cheaper, or more established alternative (Avastin for breast cancer).
- Regional variation in medical treatment. Spending on medical care varies widely across the US: in the lowest-spending areas, Medicare spends around $2000 less per person than average, and around $3500 less per person than it spends in the highest-spending parts of the country. These differences are only partly due to differences in how sick Medicare beneficiaries are in different parts of the country. Much if not most of the extra care that extra spending is buying doesn’t appear to be producing better health. Instead, the higher-spending regions are often high-supply areas, where people get a lot more treatment but don’t necessarily have better outcomes.
- International spending comparisons. The United States spends far more on health care than any other country in the world, but doesn’t get particularly good results – our population health outcomes, such as life expectancy and infant mortality rates, are worse than in most other developed countries. Part of the difference in spending is attributable to the high prices that we pay for medical care, but some of the difference is likely that we waste more on ineffective medical treatment.
- Guidelines. Most physicians are members of specialty societies, which issue guidelines about the best way to treat many conditions. For example, the American College of Cardiology has issued guidelines on when a patient is likely to benefit from stenting. A study reviewing the records of actual stent patients, however, showed that one in eight patients was inappropriate and never should have had the procedure. In other words, physicians don’t always follow sections of guidelines that recommend against treatment. On top of the 12% of patients who were inappropriate, almost forty percent of the patients in that trial were of “uncertain” appropriateness, meaning the chance that they would benefit from the treatment was questionable – most of them likely would have been no worse off with drug therapy instead of surgery, and they might have been better off.
Isn’t under-treatment the most important problem in US health care?
- Under-treatment is a real problem. When patients don’t get the treatment they need, they suffer and their families and communities suffer. The medical system absolutely must take responsibility for alleviating that suffering, and has a moral obligation to provide needed care to all patients. One of the principal reasons patients don’t get care they need is lack of health insurance, or lack of insurance that adequately covers their medical needs.
- Under-treatment isn’t just about uninsurance. Many people have difficulty accessing care, even if they have insurance, because they lack important forms of social support such as transportation, housing, and connections to family or other social networks. Social services can be essential to delivering medical care effectively, especially for poor, chronically ill populations, and the elderly.
- Under-treatment and overtreatment have many of the same root causes. Many of the same cultural influences and incentives in health care simultaneously feed overtreatment and under-treatment. For example, hospital resources that should be directed toward providing mental health care and social support may go instead to purchasing high-tech machines, such as proton therapy reactors, which is lucrative and makes a hospital look like it’s on the cutting edge of care for prostate cancer – but which haven’t been shown to improve treatment outcomes. By the same token, practices that can heal the system of overtreatment – such as more patient-centered medical education and the careful consideration of medical evidence – can be powerful tools for recognizing unnecessary suffering and understanding how to do better for the under-served.
What can I do about overuse?
- At your doctor’s office:
- When your doctor suggests a particular test or treatment, it’s OK to have questions. These five questions, adapted from the book Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, are intended to help you start a conversation and get the right care. If your doctor feels like there isn’t time to answer all of these questions in one appointment, it’s OK to ask for another.
- What are my options? For many conditions and illnesses, there can be more than one treatment. Sometimes changing your lifestyle, such as your eating or exercise habits, can reduce your symptoms or risk of a bad outcome enough to make additional treatment unnecessary. Sometimes, not getting treated at all is a reasonable choice. Ask your doctor what your options are, and to explain each one carefully.
- How exactly might the treatment help me? Sometimes patients have one idea about what a treatment can do, and the doctor has another idea. You need to know exactly what you stand to gain. A hip replacement, for example, might allow you to walk again with greater ease, but it won’t cure your arthritis, and you might need another replacement in 10 to 20 years. A drug might be able to relieve some symptoms and not others. Ask your doctor how the proposed drug or procedure is supposed to help you.
- What side effects can I expect, and what bad outcomes might happen? Every test, drug, surgery, and medical procedure has side effects, and some can be very serious. Simply being in the hospital exposes you to the possibility of bad reactions, medical errors, and hospital-acquired infections. You need to know the risks so you can decide if the danger or discomfort of your condition is more worrisome to you than the risks of the proposed treatment.
- How good is the evidence that I’ll benefit from the treatment? Many of the treatments and tests that doctors prescribe have never been adequately tested to find out if they work, or if they work in patients like you. You need to know if the treatment your doctor is recommending is a proven therapy. If not, your doctor should explain why he or she thinks it’s a good idea.
- If it’s a test, what do you expect to learn from it, and how might it change my treatment? If the test won’t change the treatment, ask your doctor if you really need the test.
- Online: Follow the Lown Institute on Twitter, Facebook, and YouTube.
- Attend our events! Our events are intended for the public, not just for clinicians. Patients, the business community, community organizations, and other elements of civil society must be represented in order to move the system toward right care – we hope you’ll come share your perspective and goals for the future of health care. Read about our Right Care Regional Events and Annual Conference.
- In your community: If you’re interested in helping us host a conversation about right care in your community, please contact our field organizer, Paul Williams, at email@example.com.
Where can I learn more about overuse?
- Our website! You can learn more about overuse on our Right Care Blog, or by checking out the books, videos, and blogs on our Resources pages.
- The NNT. The NNT is a resource for patients and clinicians that compiles high-quality evidence on the effectiveness of tests and treatments, and presents it in a clear, usable way.
- Choosing Wisely. The Choosing Wisely campaign has asked medical professional organizations to list tests and treatments that aren’t supported by evidence, and that physicians should stop doing. You can read more about the project at the Choosing Wisely website.