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Redefining 'Overuse' in Medicine to Include Cost

Yale researchers suggest new addition to treatment harms

As the cost of health care in the U.S. continues to rise, a new study by researchers at the Yale School of Medicine offers insight into a key factor influencing increased costs: overuse of medical services.

Overuse has been defined as “the provision of medical services with no benefits, or for which harms outweigh benefits,” noted the authors, led by Dr. Edward Melnick. To examine the issue, Melnick and his colleagues conducted an analysis of computed tomography (CT) scans in patients with minor head injuries.

Using published data, the researchers first identified a “testing threshold” — the point at which the risks and benefits of testing, therapy, and a missed diagnosis were equal — for ordering CT scans for minor head injuries. They calculated the testing threshold in two ways: by considering the test’s effectiveness alone and by considering its effectiveness in combination with cost. Next, they compared the two thresholds with the standard of care for minor head injuries, which has been validated by studies involving thousands of patients.

The results suggested that, based solely on the test’s effectiveness, the standard of care may not identify all patients for whom the benefits of CT scans outweigh the potential harms (small radiation exposure). When cost is factored into the equation, however, the data supported the standard of care.

“If we don’t consider cost, then we should be scanning everyone,” Melnick said. But a universal standard for CT scans would mean high costs to individuals and to society without a clear benefit in most cases, he noted, and it would also run counter to high-quality research that has already determined which patients should or should not get scans.

“We believe these findings could spark a public dialogue about the exponentially increasing costs generated as expensive testing is used on increasingly larger groups of patients at low risk of serious outcomes,” Melnick said. “We conclude that the concept of overuse should be redefined to include the provision of medical services with no benefits or for which harms, including cost, outweigh benefits."

The study was published online in the Joint Commission Journal on Quality and Patient Safety.

Source: Yale University; June 25, 2015.

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