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Jubiläum 1989–2019 UNNECESSARY HEALTH CARE Thomas Baumann Overutilization, overuse, 2. Children with isolated linear skull fractures and normal Glasgow coma scale scores do not require or overtreatment and quaternary hospitalization for observation or re-imaging. prevention 3. Using antidepressants in adolescents is likely in- The black hole in pediatrics effective and possibly harmful. 4. Most (70% to 80%) of hospitalized children with Introduction community-acquired pneumonia have a virus or Thomas Baumann In our daily business, unnecessary healthcare is not mycoplasma as causative pathogen, not bacteria. obvious. But already in 2010 the US Institute of Me- dicine (IOM) called attention to the problem, sugge- 5. Oral antibiotics are as effective as, and much sa- sting that «unnecessary services» are the largest con- fer than, peripherally inserted central catheters tributor to excessive healthcare costs, accounting for for the treatment of acute osteomyelitis. approximately $ 210 billion of an estimated $ 750 bil- lion in excess spending each year1). In previous stu- 6. The exchange transfusion threshold for infants dies of different medical subspecialties, 30% of inpa- with hyperbilirubinemia is likely too low and should tient antimicrobial therapy2), 26% of advanced ima- be raised because the risk of cerebral palsy and ging3), and 12% of acute percutaneous coronary kernicterus is extremely low. interventions were found to be unnecessary or in- appropriate4). The US academy of sciences estimated 7. Nebulized hypertonic saline is not superior to nor- in 2005 that «between $ 30 and $ 40 of every dollar mal nebulized saline for management of inpatient spent on healthcare is spent on costs poor quality he- bronchiolitis. althcare, wasted on overuse, underuse, misuse, du- plication, system failures, unnecessary repetition, 8. Routine measurement of head circumference in poor communication and inefficiency»5). While simi- the first 2 years of life is neither sensitive nor spe- lar statistics are lacking for the pediatric field, the hy- cific for neurocognitive disorders. pothesis is that the same applies to our field, thus at- tributing a rough estimate of 30% of pediatric ser- 9. Using C-reactive protein testing to screen for ear- vices to medical overuse. Interestingly though, our ly-onset sepsis in newborns resulted in longer hos- textbooks hardly ever mention the problem of medi- pitalizations and more lumbar punctures – but no cal overuse – be it the latest Nelson 2016, Wolters improvement in outcomes. Kluwer’s UpToDate Inc., or the Swiss «Paediatrica». Reducing overtreatment is essential for improving pa- 10. In evaluating acute appendicitis, replacing com- tient-centered care6), as it is directly associated with puted tomography with ultrasound reduces radi- patient harm, overuse of diagnostic testing and the ation exposure and provides the same or better inherent postoperative complications from unneces- accuracy. sary surgical procedures7). This article seeks to raise awareness of the possibility of medical overuse th- Other examples with scarce evidence until now, rough overdiagnosis in pediatrics, suggesting that could be added to this list: unnecessary antibiotics in overdiagnosis may affect commonly diagnosed con- middle ear infection, antibiotics in vaccinated child- ditions and focusing on a possible remedy, the qua- ren with suspected pneumonia, antitussive drugs, mu- ternary prevention. cus solvents, antibiotics in strepococcal pharyngitis, overuse of steroids in asthma, overtreatment with le- A literature search and systematic review of stu- vothyroxine in congenital hypothyroidism, overtreat- dies that address overuse in pediatric care by Coon ment of fever (a daily problem), overuse of stimulants, ER 20178) identified ten areas of overdiagnosis, over- excessive antibiotics in Lyme disease, treatment of treatment, and over-utilization: aspiration, antibiotics in suspected bacteremia, im- properly diagnosed food allergy, gastro-esophageal 1. Lowering oxygen-saturation thresholds to 90% reflux, threshold of hyperbilirubinemia and hypercho- for infants with bronchiolitis can safely decrease lesterolemia, hospitalization for hypoxemia in bron- Korrespondenz: lengths of stay. chiolitis, medium-chain acyl-coenzyme A dehydro- [email protected] Vol. 30 | 5-2019 33 Jubiläum 1989–2019 genase substitution9), excessive multiple drug regi- and so is the market for it (stimulants). This success- ments in epilepsy (treatment of EEG instead of fully transforms healthy people into patients, with the children), to name a few. Munchhausen by proxy syndrome as grateful team- mate of this malignant mechanisms. Overdiagnosis for adult conditions has gained a great deal of recognition over the last few years, and An important reason for these phenomena is the led to realizations that certain screening initiatives, clinician’s fear of missing a diagnosis or litigation and/ such as those for breast and prostate cancer, may be or public enthusiasm for screening or testing and de- harming the very people they were designed to pro- sire for reassurance. But the main reason probably tect. Although some initiatives exist already like are financial incentives on all levels: doctors, health «smarter medicine» or https://www.choosingwisely. insurances, hospitals and government. The potential org/topic-area/pediatrics, overdiagnosis in children consequences of overdiagnosis are psychological and has been less well described, or looked after. behavioral effects of disease labelling, physical harms and side effects of unnecessary tests or treatments, thereby lowering the quality of life affected by Definition unnecessary treatment and increased financial costs Overdiagnosis is defined as a diagnosis of a con- to individuals and public health care. dition or abnormality which will, if left alone, ne- ver cause symptoms, complications, or shorte- Factors that drive medical overuse include pay- ned life, while in overtreatment, by definition, tre- ing health care providers more to do more, exagge- atment cannot possibly help patients who are rated fear of litigation or patient’s litigiousness, and overdiagnosed10). Overuse comprises both over- the consumer’s unawareness of healthcare costs due investigation and overtreatment. Examples are to insurance coverage (whether public insurance, pri- over-utilization, over-prescription, self-referral, vate, or both). Such factors leave many actors in the manipulation of cut-off values, diagnosing non- system (doctors, patients, pharmaceutical compa- disease and inappropriate healing claims. nies, device manufacturers) with insufficient incen- tives to restrain prices or overuse. The threshold bet- Overdiagnosis occurs when a diagnosis is ween necessity and lack thereof is often subjective «correct» according to current professional stan- and based on biased studies e.g. by pharmaceutical dards, but the diagnosis or its associated treat- research sponsoring. The latter is prone to publica- ment has a low probability of benefiting the per- tion bias, omitting negative study results, which can son diagnosed. It is caused by a range of factors lead to unnecessary if not downright dangerous «tre- such as: use of increasingly sensitive tests that atments» as it was the case with Tamiflu®. Often pa- identify abnormalities that are harmless, non-pro- tients ask for drugs, devices, diagnostics, or proce- gressive, or regressive (over-detection), expan- dures purely based on advertisements, mostly la- ded definitions of disease – for example, attenti- cking any scientific basis. Service providers will on-deficit/hyperactivity disorder and dementia simply give these treatments or services rather than – and lowering disease thresholds, such as os- attempting the more unpleasant task of convincing teoporosis (over-definition), creation of pseu- the patient that what they have requested is not nee- do-diseases (also called disease mongering), such ded or likely to cause more harm than good. There as low testosterone and restless leg syndrome. are distinct traps for physicians, predisposing to over-treatment12): Causes • attempting to mitigate a risk of a disease without The basic premise – that medicine is driven by science considering how small or unlikely the potential be- and by physicians capable of making clinical decisi- nefit is ons based on well-established facts and theories – is simply incompatible with the data. It is obvious that • attempting to fix an underlying problem, instead of care providers are more important in driving demand using a less risky monitoring or coping strategies than previously thought10). For example, pharmaceuti- cal industries don’t look for patients but for consu- • acting too quickly, when waiting for more informa- mers. Possible drivers on the patient side are culture, tion might be wiser beliefs (more = better), faith (in doctors and in pre- vention), the intolerance of uncertainty, biased media • acting without considering the benefits of doing (advertising), medicalization and offers by the sellers. nothing An impressive example of the latter is the opioid cri- sis in the USA11). Others are introduction of new «qua- • suspecting a wish of the patient, or his parents, do lity measures», increased complexity of care, new gui- to something delines (e.g. cut-off values for dyslipidemia), and screening. Another phenomenon not only occurring • following unproven rules or eminence-based advice in developing countries is «because we have the ma- chine»: unnecessary examinations
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