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Top Five Examples of Overdiagnosis and Unnecessary Treatment
Sidney M. Wolfe, M.D.
The useful book by Dr. H. Gilbert Welch, “Overdiagnosed: Making People Sick in the Pursuit of Health” (Beacon Press) has previously been discussed in Health Letter. This book highlights the ways in which the conventional wisdom of the medical establishment - that early diagnosis of disease is always best - can not only fail to help patients but can also expose them to unneeded harm.
A recent article in the Archives of Internal Medicine offered examples of “diagnostic tests or treatment that are commonly ordered but that offer limited benefits or carry risks that outweigh their benefits.” The text below is excerpted from this article and outlines five best practices in internal medicine to avoid overdiagnosis.
1. Don’t do imaging [MRI or CT scan] for low back pain within the first six weeks unless red flags* are present.
- Imaging of the lumbar spine before six weeks does not improve outcomes but does increase costs.
- Low back pain is the fifth most common reason for all physician visits.
*Red flags include but are not limited to severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis [bone infection] are suspected
2. Don’t obtain blood chemistry panels (e.g., basic metabolic panel) or urinalyses for screening in asymptomatic, healthy adults.
- Only lipid screening [cholesterol, etc.] yielded significant numbers of positive results among asymptomatic patients.
- Screen for type 2 diabetes mellitus in asymptomatic adults with hypertension.
3. Don’t order annual ECGs [electrocardiograms] or any other cardiac screening for asymptomatic, low-risk patients.
- Little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.
4. Use only generic statins when initiating lipid-lowering drug therapy.
- All statins are effective in decreasing mortality, heart attacks, and strokes when dose is titrated to effect appropriate LDL cholesterol reduction.
- Switch to more expensive brand-name statins (atorvastatin [LIPITOR] or rosuvastatin [CRESTOR]) only if generic statins cause clinical reactions or do not achieve LDL cholesterol goals.
5. Don’t use DEXA [bone mineral density] screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.**
- Not cost-effective in younger, low-risk patients, but cost-effective in older patients.
**Risk factors include but are not limited to fractures after age 50 years, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking, alcoholism, thin and small build.
[Health Letter editor’s note: We disagree with the first bullet in item 4, since neither rosuvastatin (CRESTOR) nor fluvastatin (LESCOL) has been shown to decrease death, heart attacks or strokes in people with elevated cholesterol levels.]
Public Citizen’s bottom line: When it comes to unnecessary diagnostic testing, patients are advised to just say no.
Reprinted with permission from: Good Stewardship Working Group. The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism. Arch Intern Med 2011;171(15):1385-1390.