Drivers of overtesting

I strongly applaud the commentary by McGregor and Martin,¹ which highlights a long-standing but worsening problem in health care. As innovation and technology produce new forms of investigation and treatment, each has the potential to produce important benefit to patients. However, not all that is new is better, which means that many new interventions achieve nothing, or worse, cause aggregate harm. As the authors rightly note, we need to carefully evaluate both our established practices and any new innovations to assure that they can deliver meaningful, rather than just statistically significant or “false end point,” improvements to outcomes.

I would like to point out one important contributor to the issue of overtesting that the authors fail to mention: economic interest. Any process that consumes resources creates beneficiaries along the supply chain. For testing, the beneficiaries are the producers of the equipment and the consumable supplies, and the companies that provide direct service to patients. In the case of treatment, the beneficiaries are the drug and device supply companies, their distributors, and pharmacies. Unfortunately, this business influence seems to be becoming both more widespread and more subtle, including contributions to universities, research organizations, and non-profit charities. Regrettably, these same entities are heavily involved in producing the guidelines that support what the authors term creep in preventive screening and diagnosis. Unless we can be sure that we can create evaluation processes that are free from influence by parties who are in economic conflict of interest, we will not be able to address the problems of overtesting and overtreatment, nor prevent them from undermining patient and system health.