#189 Medical Overuse: Common Cases

December 23, 2019 | By Justin Berk

When Internal Medicine is Too Much of a Good Thing with JAMA authors, Drs Debbie Korenstein and Dan Morgan

Team up with the authors of the JAMA Medicine series on Medical Overuse, Dr. Dan Morgan @dr_dmorgan (University of Maryland) and Dr. Deborah Korenstein @DKorenstein (Memorial Sloan Kettering). We discuss procalcitonin (again!), the dangers of incidentalomas, risks of chest CT for lung cancer screening, the easiest place to get antibiotics for a viral infection, and why not to treat subclinical hypothyroidism despite guidelines. Trying to find ways to shed the fat off of some common medical practices? Look no further.

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Credits

Written and Produced by: Justin Berk, MD MPH MBA

Infographic: Justin Berk, MD MPH MBA

Cover Art: Matthew Watto MD, FACP

Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   

Editor: Molly Heublein MD, Matthew Watto MD, FACP, Emi Okamoto MD (written materials); Clair Morgan of Nodderly.com (audio)

Guest:  Daniel Morgan MD, Deborah Korenstein MD, FACP

Time Stamps

• 00:00 Intro, disclaimer, guest bios
• 04:45 Guest one-liners
• Picks of the Week*: The Fifth Season is part of The Broken Earth Trilogy by NK Jemisen; The Great Believers: A Novel by Rebecca Makkai; A Constellation of Viral Phenomena by Anthony Marra
• 09:22 Best advice
• 11:18 Defining Medical Overuse and defining categories
• 19:20 Procalcitonin testing for pneumonia
• 27:42 Imaging and incidentalomas
• 37:38 Lung cancer screening CT scan; the Bach model
• 46:25 Urgent care and antibiotic prescriptions for viral illnesses
• 52:43 Subclinical hypothyroidism
• 58:32 Take home points
• 61:00 Outro and Stuart tells us about his knee pain

Medical Overuse Pearls

Procalcitonin does not improve antibiotic stewardship in treating respiratory infections 

All imaging comes with a risk of incidentalomas that can lead to a cascade of testing and treatments that may cause harm

The benefit of low-dose chest CT screening for lung cancer depends on underlying risk of lung cancer; patients can be risk-stratified using the Bach model 

Urgent care facilities frequently prescribe antibiotics for viral respiratory infections

A recent meta-analysis suggests no improvement in quality of life or reduction in symptoms for the treatment of subclinical hypothyroidism

Medical Overuse Show Notes 

What is Medical Overuse 

The Institute of Medicine (IOM)  defines medical overuse as “care in which the benefits are no greater or are worse than the harms.” (Chassin & Galvin 1998)

An estimated 20 – 30% of medical care may be unnecessary (Lyu et al. 2017; IOM 2010). This has been studied mostly in the United States but has also been seen worldwide. Medical overuse often co-exists with medical underuse as well.

“Waste” is often a term to encompass  clinical redundancy because of a disconnected system.  Overuse has an impact on patient care, not just financial outcomes.

Residents know that a test is unnecessary, but often order it anyway because they want to please their attendings. (Sedrak et al. 2016)

An Update in Medical Overuse

The JAMA Medicine “Update in Medical Overuse Series” is an annual article that highlights the 10 most important articles of the year regarding overutilization of medical care. (Morgan et al. 2019) This year the articles were divided into five categories: overtesting, overdiagnosis, overtreatment, services to question, and methods to reduce overuse.

We discuss 5 of the articles with first author Daniel Morgan and senior author Deborah Korenstein.

Procalcitonin for Lower Respiratory Tract Infections (Overtesting)
Article: Huang et al. 2018  Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. NEJM. 

Previous studies have shown that procalcitonin guidance decreased unnecessary antibiotic use and improved mortality for patients with acute respiratory infections. (Scheutz et al. 2018)

Procalcitonin is thought to be an enzyme elevated in bacterial infections and may be a marker for serious infections. For bacteremia, the sensitivity and specificity for procalcitonin are estimated to be 76% and 70%, respectively. (Jones et al. 2007)

Procalcitonin did not affect antibiotic prescriptions in a real world setting.  The recent ProACT study (Huang et al. 2018) in NEJM was a randomized controlled trial that offered antibiotic guidance based on procalcitonin levels. It was a “real world” study as practitioners were able to make their own decision regarding antibiotic utilization. Clinicians adhered to the procalcitonin guidance approximately 65-73% of the time. There was no decrease in antibiotic usage with procalcitonin-guided recommendations.

Another study suggested that low procalcitonin and positive respiratory viral panel was not associated with discontinuation of antibiotic therapy at one institution. (Timbrook et al. 2015)

Check out HotCakes Episode #173 for discussion on another article observing (unsuccessful) attempts to differentiate viral from bacterial pneumonia using procalcitonin.

Med-Peds Pearl: Procalcitonin has been (successfully) used in algorithms to risk stratify infants with fever including the new PECARN Criteria and Step-by-Step approach.

Incidentalomas (Overtesting)
Article: O’Sullivan et al. 2018  “Prevalence and outcomes of incidental imaging findings: umbrella review” BMJ

In a recent survey, over 99% of physicians reported experiences with “cascades of care” after incidental findings. Patients reportedly experienced psychological harm, physical harm, and financial burden. Physicians experienced frustration, anxiety, and wasted time and effort. (Ganguli et al. 2019)

Rates of incidentalomas seem to be rising alongside rates of utilization of higher tech imaging. A previous Update in Medical Overuse paper highlighted evidence that advanced imaging for simple headache has increased. (Morgan et al. 2016)

Incidentalomas are very common. In a comprehensive review, O’Sullivan et al. 2018 quantified the rates of incidentalomas across various modalities of imaging. Incidentalomas occurred in more than a third of images in cardiac MRI, chest CT, and CT colonography.

Rates of incidentaloma malignancy depend on location. Incidental brain findings were associated with zero occurrences of malignancy while approximately 42% of breast findings were found to have malignancy (although of unknown clinical severity).  Incidentaloma was defined as:

“An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or in a symptomatic patient, where the abnormality was not apparently related to the patient’s symptoms.” –O’Sullivan et al 2018

In South Korea, increased thyroid cancer screening found increased rates of thyroid cancer without any changes in patient outcomes. (Ahn et al. 2016)

Low Dose CT Scans for Lung Cancer (Overdiagnosis)
Article: Caverly et al. 2018 “Comparison of Observed Harms and Expected Mortality Benefit for Persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project.” JAMA Internal Medicine

USPSTF Guidelines recommend: 

Annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years

The recommendation is based on the National Lung Screening Trial data from NEJM 2011 which demonstrated a 20% relative reduction in mortality from lung cancer with CT screening. (NLST et al. 2011). This trial found a number needed to screen of 320 to prevent one death from lung cancer.

Subsequent studies have raised questions about lung cancer screening.  Implementation in the VA system showed a false positive rate > 50% (compared with 26% false positive rate with NLST), with a 40:1 ratio of incidentaloma to cancer (Kisinger et al. 2017).

The article reviewed is a “Comparison of Observed Harms and Expected Mortality Benefit for Persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project.”  (Caverly et al. 2018). 

Number Needed to Screen Depends on Risk Stratification. 

When risk-stratified using the Bach Model, the highest risk group demonstrated a Number Needed to Screen of 687 to prevent one death from lung cancer, while the low-risk group had no statistical benefit from screening (although Dr Korenstein comments that this low risk group probably did not even qualify for screening). 

Dr. Korenstein’s expert opinion: Uptake of lung cancer screening has been poor, and we may be screening a lower risk population at higher rates, missing the patients who would actually benefit the most.

Dr. Williams expert opinion: These studies demonstrate the importance of pre-counseling on the risk of a diagnosis of incidentalomas.

These guidelines are also discussed in Episode #179: CHEST 2019 Recap Part #1.

Antibiotic Prescribing Patterns by Facility (Overtreatment)
Article: Palms et al. 2018 “Comparison of Antibiotic Prescribing in Retail Clinics, Urgent Care Centers, Emergency Departments, and Traditional Ambulatory Care Settings in the United States.” JAMA Int Med

This study in JAMA Internal Medicine looked at antibiotic prescribing patterns across the Emergency Department, Urgent Care clinics, and primary care offices using administrative data.

Urgent Care Clinics Prescribe More Antibiotics. 

Patients presenting to an urgent care facility with a viral infection had a 46% chance of receiving antibiotics (Palms et al. 2018). This was three times the likelihood of receiving antibiotics at a primary care office.

Dr. Morgan expert opinion: Patient are seeking attention to address their needs and there is room to talk to patients about pain relief or other antibiotic alternatives.

Not Everyone Wants Antibiotics. 

(Editor’s Note: In Pediatrics, patients presenting with requests for antibiotics may just want pain relief. —van Driel et al. 2016). In pediatrics, antibiotic prescription has been shown to correlate with perceived parental preferences for antibiotics, rather than actual parental preference. This suggests clinicians think that they know which patients want antibiotics but are often incorrect.  (Magnione-Smith et al. 1999)

Dr. William’s recommends this tool as a contingency plan for symptom relief without antibiotics: CDC Symptom Rx Pad

Time of Day Affects Prescribing Practices. 

Clinicians’ likelihood of prescribing antibiotics for respiratory infections increased for appointments later during the day (Linder et al. 2014). This is also true for opioid prescriptions (Neprash & Barnett 2019), and routine colon cancer and breast cancer screening decreased by later time of day. (Hsaing et al. 2019)

Treatment of Subclinical Hypothyroidism (Overtreatment)
Article: Feller et al. 2018 “Association of Thyroid Hormone Therapy With Quality of Life and Thyroid-Related Symptoms in Patients With Subclinical Hypothyroidism: A Systematic Review and Meta-analysis.” JAMA

Current guidelines for treatment of asymptomatic hypothyroidism vary. A recent BMJ Practice Guideline by MAGIC offers a summary of different guidelines with clinical decision-making support.

Up to 20% of asymptomatic American have subclinical hypothyroidism. (Dr. Morgan expert opinion: ([In his specialty], we just call that a false positive.)

The article looked at 21 randomized controlled trials that showed levothyroxine treatment of subclinical hypothyroidism was not associated with any significant improvement in quality of life, body mass index, blood pressure, or other significant clinical outcome (Feller et al. 2018).

Take Home Points:

1. Dr. Korenstein: “Every time we do stuff to people, we might hurt them”
2. Dr. Morgan: As clinicians we must have humility with uncertainty and talk with patients about unintended risks with medical use

Goal

Listeners will consider 5 of the top articles from 2018 that demonstrate signs of medical overuse that seem to offer more harm than benefit to patients.

Learning objectives

After listening to this episode listeners will…  

1. Define medical overuse
2. Discuss recent data about the utility of procalcitonin for antibiotic stewardship in respiratory infections.
3. Recall the frequency incidentalomas on imaging and which modalities are associated with the highest risk.
4. Identify the differences in benefits of annual lung cancer screening with CT based on baseline risk
5. Recall the lack of evidence for treatment of asymptomatic subclinical hypothyroidism
6. Describe the locations that are associated with more antibiotic prescriptions for viral infections.

Articles Discussed:

1. Morgan et al. 2019 2019 Update in Medical Overuse. JAMA Int Med
2. Huang et al. 2018 “Procalcitonin-Guided Use of Antibiotics for Lower Respiratory Tract Infection. “NEJM
3. O’Sullivan et al. 2018  “Prevalence and outcomes of incidental imaging findings: umbrella review” BMJ
4. Caverly et al. 2018 “Comparison of Observed Harms and Expected Mortality Benefit for Persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project.” JAMA Internal Medicine
5. Palms et al. 2018 “Comparison of Antibiotic Prescribing in Retail Clinics, Urgent Care Centers, Emergency Departments, and Traditional Ambulatory Care Settings in the United States.” JAMA Int Med
6. Feller et al. 2018 “Association of Thyroid Hormone Therapy With Quality of Life and Thyroid-Related Symptoms in Patients With Subclinical Hypothyroidism: A Systematic Review and Meta-analysis.” JAMA

Links*

1. The Fifth Season is part of The Broken Earth Trilogy by NK Jemisen
2. The Great Believers: A Novel by Rebecca Makkai
3. A Constellation of Viral Phenomena by Anthony Marra
4. Bach Model for lung cancer risk stratification
5. Pediatric Fever Algorithms: PECARN Criteria and Step-by-Step approach.
6.  BMJ Practice Guideline for subclinical hypothyroidism

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Disclosures

Dr. Morgan and Dr. Korenstein report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Morgan D, Korenstein D, Berk J, Williams PN, Brigham SK, Watto MF. “#189 Medical Overuse”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. December 23, 2019.