The topography of overuse

Andreu Segura

More and more voices warn about the damages associated with the excessive use of health services, although those who claim for the negative consequences attributable to precariousness and the cuts suffered by public health still prevail.

Of course, some protests as well maybe relevant since the health damages related to medical and health care are a consequence of both the action and the omission. And it isn't strange that both coexist because, for example, the abuse of imaging tests leads to an increase in the waiting list of patients who are candidates for exploration, so that the higher the proportion of superfluous prescriptions, the more they will be delayed those that are necessary, those whose result can modify the clinical decision for the benefit of the patient.

A negative consequence for the health system as a whole, to which those that directly affect patients must be added, can be classified into six areas or domains as shown in the concept map recently published in JAMA.

A map whose need is justified by its authors because, although it is clear that the abuse of tests and treatments is harmful, our understanding of the phenomenon is very limited and the quantification of its impact insufficient and, consequently, we don’t know what are the most effective measures to reduce the harmful effects of overuse.

Hence the interest in proposing new explorations of the problem, including the proposal of topography to improve their understanding, as well as facilitating communication between patients and professionals and the estimation of the damages and costs that are attributable to it with the ultimate aim of reducing the frequency of overuse and its repercussions. Of course, maps are nothing more than a graphic form of taxonomy.

Through an exhaustive review of the literature and the contest between recognized experts, six areas have been determined that include the full spectrum of damages that patients may suffer due to overuse, damages that may be acute or persistent and that can be generated shortly or long term, directly or through what is known as a therapeutic cascade, namely a series of interventions resulting from the first action.

These six regions are somatic, psychological and social - the three dimensions of health - in addition to financial, therapeutic overload and dissatisfaction with medical care. Physical damages are the ones that are most often reported, probably because they are more obvious, and although the anxiety associated with the uncertainty of a diagnostic test is easily recognized, it is more difficult to attribute a major depression to an iatrogenic disease. And the isolation attributable to an adverse effect of the treatment or other possible alterations of the social identity is rarely taken into account. As for care overload, it refers to the dependence on health services caused by a health problem attributable to abuse. The direct and indirect costs that fall on the patient are included in the financial area, while the region of dissatisfaction groups the discomfort and distrust attributable to unnecessary adverse effects.

Although it remains to be seen if the instrument is useful for clinical management, the authors have carried out a brief empirical verification for which they selected 63 examples of overused medical services, from which they obtained 54 cases that could be located in all the domains of the map. The mean negative consequences of each case were 3.2. While most of the damage occurred in the short term, more than half were the result of a waterfall, two examples of which illustrate the article that, thanks to the EVALMED initiative, can be consulted also in Spanish. One of them corresponds to a CT scan without an accurate indication, while the initial decision of the second example is an unnecessary colonoscopy.