Advances in Pediatrics

When Less is More

The Role of Overdiagnosis and Overtreatment in Patient Safety
  • Audrey D. Kamzan
    Corresponding author. David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA.
    Division of Pediatric Hospital Medicine, Mattel Children’s Hospital, 10833 LeConte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA

    David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA
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  • Elayna Ng
    Division of Pediatric Hospital Medicine, Mattel Children’s Hospital, 10833 LeConte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA

    David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA
    Search for articles by this author
      Overuse (including overdiagnosis and overtreatment), also referred to as low-value care, is a major contributor to waste in health care and causes harm to patients.


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        • Skinner J.
        Causes and consequences of geographic variation in health care.
        in: Handbook of health economics. Vol. 2. 2012 (North Holland: Amsterdam)
        • Cooper Z.
        • Craig S.V.
        • Gaynor M.
        • et al.
        The price ain't right? hospital prices and health spending on the privately insured.
        Q J Econ. 2019; 134: 51-107
        • Fisher E.S.
        • Wennberg D.E.
        • Stukel T.A.
        • et al.
        The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care.
        Ann Intern Med. 2003; 138: 273-287
        • Institute of Medicine
        To err is human: building a safer health system.
        The National Academies Press, Washington, DC2000
        • Landrigan C.P.
        • Parry G.J.
        • Bones C.B.
        • et al.
        Temporal trends in rates of patient harm resulting from medical care.
        N Engl J Med. 2010; 363: 2124-2134
        • Miller M.R.
        • Takata G.
        • Stucky E.R.
        • et al.
        Policy statement - principles of pediatric patient safety: reducing harm due to medical care.
        Pediatrics. 2011; 127: 1199-1210
        • Allen D.B.
        • Lou M.M.
        • Mullen B.
        A meta-analysis of the effect of oral and inhaled corticosteroids on growth.
        J Allergy Clin Immunol. 1994; 93: 967-976
        • Lancet T.
        Time to be serious about children's health care.
        Lancet. 2001; 358: 431
        • Gillis J.
        • Loughlan P.
        Not just small adults: the metaphors of paediatrics.
        Arch Dis Child. 2007; 92: 946-947
        • Santell J.P.
        • Hicks R.
        Medication errors involving pediatric patients.
        Jt Comm J Qual Patient Saf. 2005; 31: 348-353
      1. OECD 2014, health expenditure.
        (Available at:) (Accessed November 20 2020)
      2. OECD 2014, health status.
        (Available at:) (Accessed November 20 2020)
        • Berwick D.M.
        • Hackbarth A.D.
        Eliminating waste in US health care.
        JAMA. 2012; 307: 1513-1516
        • Shrank W.H.
        • Rogstad T.L.
        • Parekh N.
        Waste in the US Health Care System: estimated costs and potential for savings.
        JAMA. 2019; 322: 1501-1509
        • Chassin M.R.
        • Galvin R.W.
        • Donaldson M.S.
        The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality.
        J Am Med Assoc. 1998; 280: 1000-1005
        • Brownlee S.
        • Chalkidou K.
        • Doust J.
        • et al.
        Evidence for overuse of medical services around the world.
        Lancet. 2017; 390: 156-168
        • Lee C.N.
        • Hultman C.S.
        • Sepucha K.
        Do patients and providers agree about the most important facts and goals for breast reconstruction decisions?.
        Ann Plast Surg. 2010; 64: 563-566
        • Mulley A.G.
        • Trimble C.
        • Elwyn G.
        Stop the silent misdiagnosis: patients' preferences matter.
        BMJ. 2012; 345: e6572
        • Handy L.K.
        • Bryan M.
        • Gerber J.S.
        • et al.
        Variability in antibiotic prescribing for community-acquired pneumonia.
        Pediatrics. 2017; 139: e20162331
        • Brownlee S.
        • Hurley V.
        Elective heart procedures in California: a close-up of geographic variation.
        California Healthcare Foundation, 2014 (Available at:∼/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20V/PDF%20VariationCloseUpHeartProcedures2014.pdf. Accessed November 28, 2016.)
        • Brodersen J.
        • Schwartz L.M.
        • Heneghan C.
        • et al.
        Overdiagnosis: what it is and what it isn't.
        BMJ. 2018; 23: 1-3
        • Wolraich M.L.
        • Hagan J.F.
        • Allan C.
        • et al.
        Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.
        Pediatrics. 2019; 144: e20192528
        • Sherman J.
        • Rasmussen C.
        • Baydala L.
        The impact of teacher factors on achievement and behavioural outcomes of children with Attention Deficit/Hyperactivity Disorder (ADHD): a review of the literature.
        Educ Res. 2008; 50: 347-360
        • Morrow R.L.
        • Garland E.J.
        • Wright J.M.
        • et al.
        Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children.
        CMAJ. 2012; 184: 755-762
        • Visser S.N.
        • Danielson M.L.
        • Wolraich M.L.
        • et al.
        Vital signs: national and state-specific patterns of attention deficit/hyperactivity disorder treatment among insured children aged 2-5 years - United States, 2008-2014.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 443-450
        • Kuzniewicz M.W.
        • Escobar G.J.
        • Newman T.B.
        Impact of universal bilirubin screening on severe hyperbilirubinemia and phototherapy use.
        Pediatrics. 2009; 124: 1031-1039
        • Usatin D.
        • Liljestrand P.
        • Kuzniewicz M.W.
        • et al.
        Effect of neonatal jaundice and phototherapy on the frequency of first-year outpatient visits.
        Pediatrics. 2010; 125: 729-734
        • Tilburt J.C.
        • Wynia M.K.
        • Sheeler R.D.
        • et al.
        Views of US physicians about controlling health care costs.
        JAMA. 2013; 310: 380-388
        • Schleifer D.
        • Rothman D.J.
        “The ultimate decision is yours”: exploring patients' attitudes about the overuse of medical interventions.
        PLoS One. 2012; 7: e52552
        • Carman K.L.
        • Maurer M.
        • Yegian J.M.
        • et al.
        Evidence that consumers are skeptical about evidence-based health care.
        Health Aff. 2010; 29: 1400-1406
        • Korenstein D.
        • Chimonas S.
        • Barrow B.
        • et al.
        Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments.
        JAMA Intern Med. 2018; 178: 1401-1407
        • Schpero W.L.
        • Morden N.E.
        • Sequist T.D.
        • et al.
        Datawatch: for selected services, blacks and hispanics more likely to receive low-value care than whites.
        Health Aff. 2017; 36: 1065-1069
        • Schilling F.H.
        • Spix C.
        • Berthold F.
        • et al.
        Neuroblastoma screening at one year of age.
        N Engl J Med. 2002; 346: 1047-1053
        • Woods W.G.
        • Tuchman M.
        • Robison L.L.
        • et al.
        A population-based study of the usefulness of screening for neuroblastoma.
        Lancet. 1996; 348: 1682-1687
        • Sankila R.
        Lessons learned from neuroblastoma screening. Evaluation and monitoring of screening programs.
        Office for Official Publications of the European Communities, Luxembourg, Luxembourg2001: 233-242
        • Ioka A.
        • Inoue M.
        • Yoneda A.
        • et al.
        Effects of the cessation of mass screening for neuroblastoma at 6 months of age: a population-based study in Osaka, Japan.
        J Epidemiol. 2016; 26: 179-184
        • Farnan J.M.
        • Johnson J.K.
        • Meltzer D.O.
        • et al.
        Resident uncertainty in clinical decision making and impact on patient care: a qualitative study.
        Qual Saf Health Care. 2008; 17: 122-126
        • Borg M.A.
        Prolonged perioperative surgical prophylaxis within european hospitals: an exercise in uncertainty avoidance?.
        J Antimicrob Chemother. 2014; 69: 1142-1144
        • Cutler D.
        • Skinner J.S.
        • Stern A.D.
        • et al.
        Physician beliefs and patient preferences: a new look at regional variation in health care spending.
        Am Econ J Econ Policy. 2019; 11: 192-221
        • Kahneman D.
        • Tversky A.
        Prospect theory: an analysis of decision under risk.
        Econometrica. 1979; 47: 263
        • Kessler D.
        • McClellan M.
        Do doctors practice defensive medicine?.
        Q J Econ. 1996; 111: 353-390
        • Wallace E.
        • Lowry J.
        • Smith S.M.
        • et al.
        The epidemiology of malpractice claims in primary care: a systematic review.
        BMJ Open. 2013; 3: e002929
        • Clemens J.
        • Gottlieb J.D.
        Do physicians' financial incentives affect medical treatment and patient health?.
        Am Econ Rev. 2014; 104: 1320-1349
        • Mangione-Smith R.
        • DeCristofaro A.H.
        • Setodji C.M.
        • et al.
        The quality of ambulatory care delivered to children in the United States.
        N Engl J Med. 2007; 357: 1515-1523
        • Fanari Z.
        • Abraham N.
        • Kolm P.
        • et al.
        Aggressive measures to decrease “door to balloon” time and incidence of unnecessary cardiac catheterization: potential risks and role of quality improvement.
        Mayo Clin Proc. 2015; 90: 1614-1622
        • Natale J.A.E.
        • Joseph J.G.
        • Rogers A.J.
        • et al.
        Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity.
        Arch Pediatr Adolesc Med. 2012; 166: 732-737
        • Rolfe A.
        • Burton C.
        Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis.
        JAMA Intern Med. 2013; 173: 407-416
        • Sah S.
        • Elias P.
        • Ariely D.
        Investigation momentum: the relentless pursuit to resolve uncertainty.
        JAMA Intern Med. 2013; 173: 932-933
        • Fanelli D.
        Negative results are disappearing from most disciplines and countries.
        Scientometrics. 2012; 90: 891-904
        • Moynihan R.N.
        • Cooke G.P.E.
        • Doust J.A.
        • et al.
        Expanding disease definitions in guidelines and expert panel ties to industry: a cross-sectional study of common conditions in the United States.
        PLoS Med. 2013; 10: e1001500
      3. History.
        (Available at:) (Accessed November 28, 2020)
        • Wolfson D.
        • Santa J.
        • Slass L.
        Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign.
        Acad Med. 2014; 89: 990-995
      4. Facts and Figures.
        (Available at:) (Accessed November 30, 2020)
        • American Academy of Pediatrics | Choosing Wisely
        Ten things physicians and patients should question.
        (Available at:) (Accessed November 30, 2020)
      5. Additional Materials for Patients. 5 questions to ask your doctor before you get any test, treatment or procedure.
        (Available at:) (Accessed November 30, 2020)
        • Kale M.S.
        • Bishop T.F.
        • Federman A.D.
        • et al.
        Trends in the overuse of ambulatory health care services in the United States.
        JAMA Intern Med. 2013; 173: 142-148
        • Goetz C.
        • Rotman S.R.
        • Hartoularos G.
        • et al.
        The effect of charge display on cost of care and physician practice behaviors: a systematic review.
        J Gen Intern Med. 2015; 30: 835-842
        • Wegwarth O.
        • Gigerenzer G.
        Overdiagnosis and overtreatment: evaluation of what physicians tell their patients about screening harms.
        JAMA Intern Med. 2013; 173: 2086-2087
        • Romano M.J.
        • Segal J.B.
        • Pollack C.E.
        The association between continuity of care and the overuse of medical procedures.
        JAMA Intern Med. 2015; 175: 1148-1154
        • Légaré F.
        • Labrecque M.
        • Cauchon M.
        • et al.
        Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial.
        CMAJ. 2012; 184: E726
        • Zafar S.Y.
        • Chino F.
        • Ubel P.A.
        • et al.
        The utility of cost discussions between patients with cancer and oncologists.
        Am J Manag Care. 2015; 21: 607-615
      6. The Do No Harm Project | Division of General Internal Medicine | University of Colorado Denver.
        (Available at:) (Accessed November 30, 2020)