You probably feel like you have been reading a lot about medical overuse these days.
You are right.
The number of articles in academic journals addressing overuse has nearly doubled this past year compared to 2014. A recent systematic review published in JAMA Internal Medicine uncovered 821 articles on medical overuse in academic literature during the 2015 calendar year. That doesn’t even include all of the editorials and articles that have been popping up in our trade journals and in popular magazines and newspapers.
What’s more, I don’t think this is the peak yet. In fact, research on overuse is basically just getting started.
Why is medical overuse such an important issue?
Overuse is not only expensive; it is a patient safety issue, since it leads to serious patient harms and downstream consequences. As hospitalists, we know this all too well. We are the ones that take care of the patients who develop C. diff colitis after a course of unnecessary antibiotics. We see the patients with contrast-induced nephropathy following CT scans. We admit the patient who overdosed on their opiates. We deal with complications from procedures and sometimes look back and say, “Why did that ever get done in the first place?”
As we have discussed in these blogs before, the sobering reality is that more than one-third of health care delivered today may not make patients any healthier, and a substantial portion of that unnecessary care causes harms. A lot of that harm happens in hospitals.
In 1998, the Institute of Medicine identified three categories of quality issues: underuse, misuse, and overuse. Since that time, although significant improvements have been made to address underuse of appropriate care, there has been relatively little progress in curbing overuse.
That is about to change.
What areas did the review highlight that are most relevant to hospitalists?
The JAMA IM review selected the most impactful studies that were likely to reduce overuse of medical care.
There was a large range of targets covered, but only a few of these areas are directly actionable by hospitalists. I will expand upon the top three that are most important to hospitalists here. So, yes, this is essentially a Top 3 list review of a Top 10 list review, but considering all of our busy lives, I will just say “you’re welcome.”
During training, when picturing ourselves as future hospitalists, it is unlikely that taking a blood pressure, making the diagnosis of orthostatic syncope and recommending drinking some water was the picture we had in mind. Low-risk syncope is boring, but we evaluate it a lot.
In this retrospective study, more than one-third (34%) of all syncope admissions were for patients who met criteria for low-risk syncope, a condition that does not warrant hospitalization.
And once they are hospitalized, what happens? They get testing, of course. A lot of it. These low-risk patients received a mean of 10.8 tests during their short hospital stay, with nearly all of them going through either the CT scanner (88%) or that donut-shaped MRI magnet (19%). If you do the quick math, it seems at least a few of them had both tests. Many of them also had echocardiograms, some had ultrasounds, and of course essentially everyone was hooked up to telemetry. Not surprisingly with all that testing, nearly a third of patients uncovered incidental findings, which often led to further recommended testing.
Nine patients (13%) suffered adverse events during hospitalization.
Hospitalist groups, such as the fantastic folks at Mt. Sinai, presented similar findings at this past year’s SHM meeting. Some of those same authors were involved in the winning idea to combat this problem, which they called “Stand Up To Syncope,” at this year’s “Costs of Care: Shark Tank” workshop.
Opiates, Even After Overdose
One of the most impactful moments at last year’s SHM conference, Hospital Medicine 2016, was the keynote presentation by our Surgeon General, fellow hospitalist Dr. Vivek Murthy. He clearly declared the national agenda to tackle opiate overuse. Although it is a challenging task, hospitalists seem to be willing to take it on. Recently, SHM launched the RADEO (Reducing Adverse Drug Events related to Opiates) program to help.
As tricky of a problem as opiate overuse is, there is one obvious situation where we should clearly do better. After a patient is hospitalized for the life-threatening condition of prescription opiate overdose, surely they should not be handed a secure script.
Well, according to a large retrospective cohort study, within 10 months of a nonfatal overdose, 91% of these patients again received opioid prescriptions. Approximately 7% of patients had a repeated overdose.
When patients are hospitalized with overdose, we need to use that as a critical moment “to identify and refer patients for substance abuse treatment to discontinue opioid prescriptions.”
Overdiagnosis of C. diff due to molecular testing
Is there a bigger nemesis for hospitalists than C. diff? Perhaps not.
However, it is possible that we are actually overdiagnosing and overtreating this nasty disease. A cohort study over two years found that PCR testing detected twice as much C. diff as the toxin method. The PCR results were not reported to clinicians, and thus, the vast majority of patients that were positive by PCR testing but negative via toxin testing did not receive any specific C. diff treatment. They actually did completely fine (median of 2 days of diarrhea), and their outcomes were similar to patients that were negative for both PCR and toxin tests.
This study result supports protocols that check PCR positive results with a reflex toxin test and only treat patients that have both tests positive, except in rare circumstances.
Now go forth, test and treat patients in hospitals – just don’t overdo it.
Christopher Moriates, MD is a hospitalist, the assistant Dean for Healthcare Value and an Associate Professor of Internal Medicine at Dell Medical School at University of Texas, Austin. He is also Director of Implementation Initiatives at Costs of Care. He co-authored the book Understanding Value-Based Healthcare (McGraw-Hill, 2015), which Atul Gawande has called “a masterful primer for all clinicians,” and Bob Wachter said is “essential reading for everyone who care about making our system better.”