Development of a Conceptual Map of Negative Consequences for Patients of Overuse of Medical Tests and Treatments

Abstract

Importance: Overuse of medical tests and treatments is an increasingly recognized problem across health systems; best practices for reducing overuse are not clear. Framing the problem in terms of the spectrum of potential patient harm is likely to be an effective strategy for clinician and patient engagement in efforts to reduce overuse, but the scope of negative consequences of overuse for patients has not been well described.

Observations: We sought to generate a comprehensive conceptual map documenting the processes through which overused tests and treatments lead to multiple domains of negative consequences for patients. For map development, an iterative consensus process was informed by structured review of the literature on overuse using PubMed and input from a panel of 6 international experts. For map verification, a systematic review was performed of case reports involving overused services, identified through literature review and manual review of relevant article collections. The conceptual map documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. Case reports on overuse confirmed the processes and domains of the conceptual map. Cases also revealed strengths and weaknesses in published communication about overuse: they were dominated by physical harms, with other negative consequences receiving far less attention.

Conclusions and relevance: This evidence-based conceptual map clarifies the processes by which overused tests and treatments result in negative consequences for patients; it also documents multiple domains of negative consequences experienced by patients. The map will be useful for facilitating comprehensive communication about overuse, estimating harms and costs associated with overused services, and informing health system efforts to reduce overuse.

Figure 1.. Conceptual map

The conceptual map demonstrates that an overused service can lead directly to short- and/or long-term negative effects on patients across six domains. Overused services and negative effects can also lead to downstream services that themselves can lead to negative effects.

Figure 2.. Examples of the overuse cascade

Case examples in which an abnormal result of an unnecessary test leads to a series of downstream services. These services may represent appropriate responses to abnormal findings or may include additional unnecessary services or medical errors, leading to negative effects on patients. Panel A: Unnecessary screening low-dose CT scan (overused service) revealed scattered nodules. This finding led to a 3-month follow-up scan, which then led to a PET scan, a surgical evaluation, and ultimately another follow-up scan. Panel B: Unnecessary colonoscopy revealed a polyp; biopsy was initially misread as high-grade lymphoma, which precipitated hospital admission with bone-marrow biopsy, PET scan, and multiple blood tests. Ultimately the biopsy was re-reviewed and findings were reclassified as benign.

Figure 3.

Examples of the overuse cascade