Table 1.

Direct and Indirect Evidence of Overuse Globally

Clinical Category	Direct documentation of inappropriate care	Indirect evidence
Musculoskeletal procedures	Spain: Rates of inappropriate total knee replacement of 26% and of total hip replacement 25% 49 US: Rate of inappropriate total knee replacement 34% 50	International: 4-fold variation across countries and 2–3 fold variation within countries in rates of knee replacement 51 England: 13-fold regional variation in rates of arthroscopic knee lavage52 US: 5-fold regional variation in adjusted rates of total hip and knee replacement 53
Cardiovascular procedures	Italy: Rate of inappropriate percutaneous coronary intervention (PCI) 22% and of inappropriate coronary angiography 30% 54 US: Rate of inappropriate PCI 1.1% for acute indications and 11.6% for non-acute indications with variation across hospitals (6.0%–16.7%) 55 Brazil: rate of inappropriate coronary angiography 20% 56	International 9-fold variation in use of PCI and 5-fold variation in use of CABG across OECD countries 28 US: Rates of elective percutaneous coronary interventions vary 10-fold within the state of California57 India: A second opinion centre reported recommending against cardiac interventions in 55% of patients in whom intervention initially recommended58
Hysterectomy	Taiwan59: 20% of hysterectomies inappropriate Switzerland60: 13% of hysterectomies inappropriate US61: rates of inappropriate hysterectomies between 16% and 70% across studies	Canada62: 2.7-fold variation in rates of hysterectomy across regions within Ontario Netherlands63: 2.2-fold regional variation in rates of hysterectomy of bleeding; 2.3-fold regional variation in rates for pelvic organ prolapse India64: prevalence of up to 9.8% overall, with 1/3 of hysterectomies performed in women under age 35 (likely inappropriate in this age group)
Antibiotics for acute diarrhea	Italy65: among children hospitalized for acute diarrhea, 9% received antibiotics inappropriately China66: 57% received antibiotics inappropriately; among those with an indication for antibiotics, 21% were NOT treated (adults) Thailand67: 55% of children with acute diarrhea received antibiotics inappropriately	US68: 10.4% of patients with diarrhea received antibiotics (often likely inappropriate) India69: 71% of children with acute diarrhea received antibiotics (despite recommendation against routine use) India70: Rates of antibiotic use for acute diarrhea 43% in public facilities and 69% in private facilities (despite recommendation against routine use)