JAMA: Cardiac procedures among the 10 most unnecessary, overused treatments of 2016

Overtreatment, overtesting and overdiagnosis were themes of a JAMA: Internal Medicine review this month that explored 10 of the riskiest instances of medical overuse in 2016.

Daniel J. Morgan, MD, MS, and four colleagues narrowed more than 1,000 articles concerning medical overuse to 122 before identifying 10 articles they found the most poignant. The studies explored a span of methodologies and equipment used in cardiology, including transesophageal echocardiography, computed tomography, carotid ultrasonography and other procedures whose proven harms outweigh potential benefits. These are the highlights.

1. Stroke patients are likely better off without certain types of echocardiography.

Transesophageal echocardiography (TEE) has been suggested as a more sensitive method of detecting cardiac causes of stroke in heart patients when compared with transthoracic echocardiography (TTE). This improved sensitivity, though, doesn’t appear to mask the potential risks patients can face as a result of TEE, including embolism, and the test is invasive and requires sedation. Morgan and co-authors wrote TEE hasn’t been proven to improve clinical care of acute ischemic stroke patients, either.

2. A disagreement over how to test for pulmonary embolism (PE) in patients is resulting in treatment delays, harm to patients and higher costs.

Diagnostic algorithms, especially D-dimer, are recommended for testing patients with low to intermediate probability of having PE. However, despite the general recommendation of D-dimer as an initial test, more hospitals are using computed tomography pulmonary angiography (CTPA). One study of an academic hospital suggested overuse of CTPA and both over- and underuse of D-dimer testing, resulting in unnecessary physical—and fiscal—harm to patients.

3. Overuse of computed tomography (CT) testing is leading to radiation exposure, cancer risk and overdiagnosis.

Between 2009 and 2010, emergency department use of CT quadrupled—mostly among patients with non-acute upper respiratory tract symptoms. Though these numbers have increased, Morgan and co-authors noted, patient management hasn’t improved. Overtesting using CT can lead not only to potential overdiagnosis, but also exposes patients to ionizing radiation, which causes up to 2 percent of all cancers in the U.S.

4. Nearly 95 percent of carotid ultrasonography for asymptomatic patients is performed for uncertain or inappropriate reasons.

Carotid ultrasonography was found to be appropriate in just 5.4 percent of patients who underwent carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009, Morgan and colleagues wrote. While it was deemed inappropriate in 11.2 percent of patients, the majority—83.4 percent—were classified as uncertain. Still, thousands of patients undergo the testing each year, exposing them to risks like vertigo, syncope, vision issues and dizziness.

5. Prostate-specific antigen (PSA) screening is more harmful than it is beneficial in men with localized prostate cancer.

In addition to this fact, many men with PSA-detected prostate cancers are treated with surgery or radiotherapy, which can result in lower quality of life, incontinence and erectile dysfunction, Morgan and co-authors wrote. Men treated with active monitoring have routinely seen higher quality of life, and PSA testing should “generally be avoided,” according to research.

6. Doctors could cut costs and harm to patients with chronic obstructive pulmonary disease (COPD) by limiting use of supplemental oxygen.

Supplemental oxygen treatment has been proven to prolong survival in patients with chronic COPD, according to Morgan and colleagues, but doesn’t seem to benefit patients with stable COPD and moderate resting or exercise-induced desaturation. Limiting use of the treatment could result in less risk of tripping, fewer supplemental oxygen-associated risks and more affordable treatments.

7. Surgery won’t improve long-term mechanical symptoms of patients with degenerative meniscus tears.

According to a 2016 study, clinicians should stick to conservative management techniques rather than invasive surgeries in patients with meniscal tears. Research has led scientists to believe there isn’t a difference in outcome between patients treated with physical therapy versus those who underwent a partial meniscectomy.

8. Clinicians should avoid nutritional support for medical inpatients at risk for malnutrition.

Although the intent seems honorable, a medical review of thousands of inpatients who were either malnourished or at risk for malnutrition showed there was no difference in mortality between patients who received nutritional counseling or intervention and those who didn’t. There was also no difference in hospital-acquired infections, functional outcomes or length of stay.

9. Up to half of all antibiotic use is inappropriate.

The wrong antibiotics can expose patients to adverse drug events, resistent bacteria and infections, one study of practices in Boston and Los Angeles concluded. Outpatient prescriptions can be improved with clinician feedback of metrics of inappropriate use.

10. Decision-making aids could reduce hospitalizations and expensive testing in cardiac patients.

The past decade has seen a more than threefold increase in advanced cardiac imaging for patients who enter the ER for chest pain, Morgan and colleagues wrote. Giving patients the option of a decision aid can help reduce hospital admissions for cardiac testing and result in fewer invasive tests and interventions. Patients who used decision aids also tended to be more informed about their risk for acute coronary syndrome, the research stated.

“Several themes emerge from our review of the overuse literature from 2016,” Morgan and co-authors wrote. “Overreliance on high-technology imaging continues apace. 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.”