Medical Overuse of Therapies and Diagnostics in Rheumatology

Abstract

Objective:

Medical overuse leads to a burden on healthcare costs and potentially is harmful to patients. We wanted to address medical overuse in musculoskeletal disease and Rheumatology.

Methods:

We performed a systemic literature review from Pubmed and Embase to study medical overuse. On the initial screen, 1499 studies were identified, 839 of them were related to medical overuse. Out of these, 52 were related to overuse in musculoskeletal diseases. Finally, 20 articles were chosen for this systemic review that reported overuse in Rheumatology.

Results:

The article identifies issues with overtesting, including the use of dual-energy X-ray absorptiometry to screen for osteoporosis in women younger than 65 years old; and the use of magnetic resonance imaging to evaluate for osteoarthritis. Studies related to overtreatment, reported over-prescription of vitamin D supplements resulting in vitamin D toxicity; and increased risk of inappropriate prescriptions in patients with osteoarthritis and rheumatoid arthritis. Overtreating osteoporosis was reported after industry-sponsored education. Articles describing methods to reduce overuse included a study showing the reduction of unnecessary dual-energy X-ray absorptiometry scans after the introduction of the Choosing Wisely Campaign.

Conclusions:

Our findings suggest that there is some evidence that overtesting and overtreatment may be present in the field of rheumatology. This review aims to highlight this and help rheumatologists to be aware of overuse practices and provide appropriate evidence-based health care.

Introduction:

Overuse is defined as “a healthcare service that is provided under circumstances in which its potential for harm exceeds the possible benefits.”¹ Medical overuse has gained increased attention recently as it causes discomfort to the patient and increases healthcare costs². Overuse involving over-testing increases the likelihood of false-positive results, often requiring further investigation, a phenomenon known as “diagnostic cascade.”³ Aiming to reduce overuse is an appealing way to reduce financial harm and improve healthcare quality and value. Updates on overuse in internal medicine have been addressed in a yearly series^4–9. There have also been studies regarding overuse in pediatrics^10–11. Overuse, however, has not previously been discussed explicitly in the rheumatology literature.

This article aims to help physicians provide care that is evidence-based and avoid unnecessary testing. Articles are classified into the following categories: overtesting, overtreatment, and methods to reduce overtreatment.

Methods:

We conducted a systemic literature review to study medical overuse in the year 2018. We searched PubMed and Embase to identify articles about medical overuse that were published, using keywords that were “overuse”, “overtreatment”, “overdiagnosis”, “inappropriate”, and “unnecessary”.

Studies related to adult and pediatric patients with rheumatic and musculoskeletal diseases were included. The structured literature review identified 1499 articles; medical overuse was addressed in 839 articles. We reviewed the titles of the 839 articles and identified 52 related to overuse in musculoskeletal diseases; of these, 32 were excluded. Of these excluded studies, ten articles were either case reports, editorials, opinion pieces, and 22 related to orthopedic issues (Figure 1). The remaining 20 articles and abstracts related to rheumatic and musculoskeletal diseases were classified into three categories: overtesting, overtreatment, and methods to reduce overtreatment (Supplemental Table 1).

Figure 1:

Review process for all articles

Results:

Overtesting

There were four articles related to the overuse of imaging studies.

Measuring overuse with electronic health records

Isaac and colleagues reported that screening for osteoporosis with dual X-ray absorptiometry in women younger than age 65 was overused based on a review of electronic health record data¹². 57% of these scans seemed unnecessary.

Automated EHR extracts for one arm of the study, and manual chart review for the other arm, were employed to identify risk factors for most clinical tests. For bone densitometry exams for women younger than 65, manual chart review did not recognize any additional risks (3.0%). EHRs can capture clinical information that often explains why a test is clinically indicated. However, although more laborious, manual chart review can identify the presence of important risk factors that automated EHR data extracts cannot.

Overuse of Magnetic Resonance Imaging (MRI) in the Diagnosis and Treatment of Moderate to Severe Osteoarthritis

With a high prevalence of knee osteoarthritis (OA), it is important to have a cost-effective way of diagnosing and managing it. While clinical examination and radiographs are enough to diagnose moderate to severe OA, some providers routinely order MRI for initial evaluation of these patients. While MRI can help visualize pathology in OA patients that is not present on radiography – including bone marrow lesions, ligamentous damage, and meniscal tears, the clinical relevance of these findings and implications for surgical treatment in severe OA is not well understood.

This study was done by Sherman and colleagues¹³. Of 145 patients with moderate to severe osteoarthritis referred for total knee replacement, 19 (13.1%) presented with a completed MRI scan. There was a significant difference between physicians versus non-physicians, with physicians ordering fewer MRI scans (p=0.018). There was a significant difference when comparing non-academic versus academic, with academic providers ordering fewer MRI scans (p=0.044). 13.1% of patients with radiographically obvious knee OA obtained an MRI prior to referral for total knee replacement.

This implies that non-physician providers are more likely to order MRI of knees in moderate to severe osteoarthritis patients.

Gouty arthritis: Can we avoid unnecessary dual-energy computerized tomography (DECT) examinations using prior radiographs?

Monosodium urate monohydrate (MSU) crystals are the hallmark for the diagnosis of gouty arthritis. The precipitated urate crystal deposits in advanced stages of gout can be detected on radiographs or CT images as radiopaque/hyperdense soft tissue deposits. However, the imaging appearance of such dense deposits is nonspecific. They can be found in other crystal arthropathies like calcium pyrophosphate dihydrate deposition disease (CPPD), hydroxyapatite crystal deposition disease, and even as secondary crystal deposition in osteoarthritis. DECT scan can distinguish between urate and non-urate crystal deposits.

This medical records review study by Kupfer et al. evaluated if conventional radiographs can serve as the gatekeeper before DECT scan to exclude radiopaque deposits¹⁴. Seventy-seven clinically indicated DECT examinations of the hand (n = 29), foot (n = 36), and ankle (n = 12) of 55 patients with suspected gouty arthritis were included. DECT showed soft tissue deposits in 54/77 DECT (70%) scans. 30/54 scans (56%) showed deposits on the corresponding radiographs, while in 24 scans (44%) no deposits were seen on radiographs. Test performance of radiographs for soft tissue deposit detection: sensitivity 56%, specificity 100%, PPV 100%, NPV 48.9%, and accuracy 69%.

Authors state that in the workup for gouty arthritis, their clinical experience has shown that in around half of the performed DECT examinations, no hyperdense deposits were found, and therefore the DECT examinations were useless. The results of this study indicate that radiographs prior to DECT cannot reliably exclude the presence of radiopaque deposits in gouty arthropathy, and thus, cannot reduce unnecessary DECT scans. Therefore, only clinical judgement can be used regarding the decision to obtain a DECT scan.

Frequency of inappropriate inpatient Computerized tomography (CT) scans

Bianco et al. showed that the frequency of inappropriate inpatient CT scans and MRI scans was highest in the musculoskeletal system, including scans performed for extremity pain and neuropathies¹⁵.

The frequency of inappropriate CT scans of the musculoskeletal system was 64.7%. Reliance on CT scans and MRI scans for evaluating inpatient musculoskeletal complaints should be discouraged, and clinical diagnosis should be stressed.

Overtreatment

This review identified seven articles and three abstracts from national conferences related to overtreatment in rheumatology.

Does industry-sponsored education foster overdiagnosis and overtreatment of osteoporosis?

The role of pharmaceutical industry-sponsored educational events has been controversial. In the presence of proper controls, it can be educational for physicians.

This medical records review study examines industry-sponsored events in Australia from a specified time-period for three conditions potentially subject to overdiagnosis and overtreatment. 1375 events were identified, focusing on osteoporosis. Increased medication sales identified overtreatment of osteoporosis after industry-sponsored educational events related to denosumab, a medication for osteoporosis treatment. This study by Mintzes showed that denosumab prescriptions increased nearly sevenfold over the study period¹⁶. Amongst those receiving these new prescriptions, the percentage of patients meeting the diagnostic criteria of osteoporosis was unclear. The majority of educational events on osteoporosis were sponsored by makers of denosumab.

A review of the growing risk of vitamin D toxicity from inappropriate practice

For Vitamin D supplementation, either oral ergocalciferol (vitamin D2) or cholecalciferol (vitamin D3) is recommended. The features of vitamin D toxicity are mediated through hypercalcemia, and symptoms range from thirst and polyuria, to seizures, coma and death. Taylor and colleagues described a case series of over-prescription of vitamin D supplements resulting in Hypervitaminosis D¹⁷. Three main themes emerged. Of the 44 studies included, 20 were related to errors in the formulation, 17 were about erroneous prescribing, and 7 reports were related to errors in administration.

Majority of the cases of Vitamin D toxicity are preventable. Standardized Vitamin D formulations and education of providers regarding cautious prescribing and monitoring can prevent toxicity.

Prevalence of potentially inappropriate medications use among older adults

Another article by Alhawassi et al. revealed that elderly patients with chronic medical conditions were more likely to have inappropriate medications¹⁸. 51.2% of patients with osteoarthritis and 50% of osteoporosis patients had inappropriate medications, such as NSAIDs prescribed.

Inappropriate prescriptions in patients with chronic kidney disease

Laville and colleagues reported that anti-gout medications were frequently inappropriately prescribed in patients with chronic kidney disease¹⁹. Amongst patients receiving anti-gout preparations, 40.5% of patients had at least one inappropriate prescription, and 2.7% had at least one contraindicated drug prescribed. Stamp et al. responded to this article stating that restricting maintenance allopurinol dose according to kidney function was inappropriate practice and led to undertreatment of gout. Careful medication review is essential for patients with chronic kidney disease to prevent adverse events.

Assessment of potentially inappropriate medications in the elderly and correlation with a history of rheumatoid arthritis

In a study done by Sakr and colleagues, 350 patients (mean age = 73.49 years), taking a total of 1893 medications, were enrolled from community pharmacies²⁰. 6.2% and 20.4% of the medications were inappropriate according to the STOPP and Beers lists, respectively. Having a history of rheumatoid arthritis increased the risk of having inappropriate medication prescriptions such as NSAIDs, which also decreased satisfaction among patients.

Inappropriate prescriptions and omissions in hospitalized patients

Akkawi et al. found that musculoskeletal medications were the most common potential prescribing omissions in hospitalized patients at admission and discharge using START/STOPP criteria²¹. The inappropriately prescribed medications highlighted in this study were NSAIDs, colchicine, and xanthine oxidase inhibitors in chronic gout. Also, vitamin D supplementation was inappropriately omitted in 13.3% of elderly patients with a history of falls and osteopenia.

Osteoarthritis is a risk factor for inappropriate prescriptions in outpatient settings

In a study by Almeida et al., a total of 227 patients ≥60 years of age were included²². The frequency of inappropriate medication use was 53.7% for Beers criteria. Potentially inappropriate medications in elderly patients in this outpatient setting were often associated with musculoskeletal diseases like osteoarthritis.

Serum Uric Acid Lowering Treatment Appears Unnecessary during Hemodialysis

Though some reports suggested that tophi disappear in gout patients after initiation of hemodialysis (HD), urate-lowering agents are frequently continued, often based on persistent high uric acid levels before HD.

In this study by Soriano et al., uric acid levels were determined before and after HD sessions in consecutive 96 patients with end-stage renal disease (ESRD)²³. Mean time on HD was 7.1 years (±7.2). Before starting HD, 43.0% had hyperuricemia and 21.6% reported gout. Sixteen (16.4%) continued on urate-lowering agents after HD. Mean uric acid levels before and after HD session was 5.2mg/dL (± 1.0) and 1.0mg/dL (±0.4), respectively. Mean uric acid reduction following HD was 80.2% (95%CI 78.4–82.0); 51 patients (56.7%) showed uric acid reduction ≥80%. Under HD replacement, uric acid levels were effectively reduced. Thus, continuing urate-lowering agents during hemodialysis seems unnecessary.

A large proportion of patients with non-septic acute arthritis receive unnecessary invasive treatments

In pediatric emergency rooms, patients with acute joint swelling can be categorized as septic arthritis, juvenile idiopathic arthritis, and undifferentiated arthritis.

Thomas and colleagues conducted a medical records review study analyzing clinical and biological data corresponding to 129 joint aspiration samples collected from 118 patients within two years²⁴. The final diagnosis of acute arthritis was septic arthritis for 45 patients (38.1%), undifferentiated arthritis for 39 patients (33%), juvenile idiopathic arthritis for 23 patients (19.5%) and 10 patients (8.5%) had other diagnoses. Antibiotics were administered in 97.8% of patients with septic arthritis, 39.1% of patients with a final diagnosis of juvenile idiopathic arthritis, and 84.2% with undifferentiated arthritis. Arthrotomy was performed in 62.2% of patients with septic arthritis, 30.4% of patients with juvenile idiopathic arthritis, 46.1% of patients with undifferentiated arthritis and 50% of patients with other diagnoses.

A large number of patients with non-septic arthritis receive unwarranted invasive treatments. To prevent this, there needs to be an emphasis on educating providers about non-invasive diagnostic markers for pediatric acute arthritis.

Thyroid hormone treatment and hormone levels among fibromyalgia patients

Some studies have suggested an association between thyroid autoimmunity and fibromyalgia. Other literature suggests that thyroid hormone treatment in fibromyalgia might be unnecessary.

In this study by Varinen et al., fibromyalgia patients were searched from the EHR²⁵. Information from thyroid hormone treatment and thyroid-stimulating hormone (TSH) and free thyroxine (T4-V) levels was obtained from patient records. 96 patients had fibromyalgia according to ACR 2010 criteria. From that group, 33 (34%) had thyroid hormone treatment and 63 (66%) had not. Statistical significance was not found between those taking thyroid hormone replacement and those not taking it, in functional ability (p=0.36) or depression (p=0.71). Of those patients with thyroxine treatment, 63% of patients had hypothyroidism based on the laboratory tests, and 37% had normal thyroid function at the beginning of the treatment.

More than one-third of fibromyalgia patients used thyroid hormone treatment unnecessarily and had normal initial thyroid function. These patients likely took the treatment to combat fatigue, a common symptom for thyroid diseases and fibromyalgia. However, the treatment essentially cannot improve fatigue if the underlying etiology is not thyroid related.

Methods to Reduce Overuse

There were five studies and one conference abstract related to methods for overuse reduction.

A new decision tree for diagnosis of osteoarthritis in primary care

Martel-Pelletier et al. conducted a study deemed useful for a definitive diagnosis of osteoarthritis by primary care physicians²⁶. Previously regarded as a “degenerative wear and tear” condition, OA is increasingly being recognized as a dynamic joint pathological process caused by destruction and repair. Interventions such as improving general practitioner training regarding OA pain can improve patient outcomes. Therefore, there was a need to establish guidelines for the diagnosis of OA in the primary care setting. A one-page decision tree was formulated to diagnose osteoarthritis in the hip, knee, and hands. In a two-phase validation stage, the guidelines were evaluated by rheumatologists for broad application. For each affected joint, a diagnosis of OA would be made based on joint pain, age (over 50 years), and the presence of joint space narrowing and/or osteophyte(s) on plain radiographs. Red flags like effusion of joint would necessitate early referral to the specialist. This practice may reduce unnecessary joint procedures and delay in proper care for patients with osteoarthritis.

Reducing Unnecessary Vitamin D Screening in an Academic Health System

Vitamin D screening can dictate decisions to upscale therapy in diseases like osteoporosis. Petrilli et al. conducted a quality improvement intervention to decrease unnecessary vitamin D testing among primary care adult patients at an academic medical center²⁷. They created an electronic alert mentioning reasons not to order the screening test unless high-risk conditions were present. After the advisory alert intervention in February 2017, 3 months of accelerated decline were observed; the monthly percentage change was −21.5% (95% CI, −26.0 to −16.8%) for low-value orders and −11.0% (95% CI −14.9 to −6.9%) for potentially appropriate orders. Implementing an electronic advisory alert reduced unnecessary vitamin D screening, but it also reduced clinically indicated vitamin D testing. These results imply that there needs to be an intervention that will not affect clinically appropriate testing.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions

Emprechtinger et al. evaluated different methods to detect overuse of CT scans and MRI scans to diagnose musculoskeletal conditions of hips, ankles, and knees²⁸. These methods included a comparison to established guidelines, expert panels, and surgery findings. A single method of choice to detect inappropriate use of CT and MRI scans was not found.

Evaluation of a prospective drug utilization review system on inappropriate prescriptions

Kim et al. reported that implementing a drug utilization review system is associated with better patient outcomes in musculoskeletal disorders in the outpatient setting²⁹. Reduction in drug-drug interactions (3.6%) related to NSAIDs use and an increase in the use of gastro-protective drugs (0.6%) was reported after introducing the utilization review system.

Choosing Wisely initiative in Ambulatory Medicine Offices

Pugel and colleagues showed that non-beneficiary services in ambulatory settings were reduced after the introduction of Choosing Wisely initiative³⁰. Amongst other changes, inappropriate DEXA scan use decreased by 23.4 percentage points (95% CI = 22.5–24.5), from an average of 25.4% to 2.0%. This implies that the Choosing Wisely initiative can be implemented to reduce unnecessary care in clinic settings.

The application of the rACR scoring system in the diagnosis of giant cell arteritis

Temporal artery biopsy is considered the gold standard for diagnosing giant cell arteritis. Hamlin et al. investigated the utility of the revised (American College of Rheumatology (ACR) criteria compared to the original ACR criteria in reducing unnecessary temporal artery biopsy³¹. A medical records review study with 53 samples of temporal artery biopsy was done, and the ACR score was calculated. All 11 positive biopsies were in the 3–5 score range. 45 patients were analyzed with revised ACR scores. Of the 11 positive biopsies, 2 were in the 3–4 score range, and 9 were in the 4–5 score range. In the ACR method, 36% of all biopsies scored as low-risk pre-biopsy. In the revised ACR method, 84.4% of all biopsies scored in the low and intermediate-risk group pre-biopsy.

Revised ACR criteria can be used to stratify patients into a low, intermediate, or high-risk category. This implies that performing biopsies in low and intermediate-risk groups is useful, but performing them in high-risk patients seems unnecessary.

Discussion

A number of studies discussed in this review have identified some overuse practices related to rheumatic and musculoskeletal diseases. These articles have followed three guideline systems that address overuse: Choosing Wisely Campaign, Beers criteria, and START/STOPP criteria. The Choosing Wisely Campaign was initiated in 2012 and focused on avoiding wasteful medical services³². The studies included in this review should promote the concept of discussion between physicians and patients regarding the use of medical care based on guidelines by expert national medical societies.

Beers criteria is a robust guideline for medical practitioners to improve the practice of inappropriate prescriptions in elderly patients.

STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are newer tools for clinicians to avoid unnecessary prescriptions in the older population. Attention to these guidelines is important in preventing drug-drug interactions and high healthcare costs. In patients with osteoarthritis, inappropriate use of NSAIDs can be reduced if these guidelines are followed. Co-administration of NSAIDs, aspirin, and warfarin can potentially increase the risk of gastrointestinal bleeding. Clinicians are encouraged to be mindful of such potential adverse events in the elderly.

Industry-sponsored events on diseases like osteoporosis usually target primary care physicians. The cost-effectiveness of advertised drugs is usually not optimal. It can lead to the physicians being biased towards prescribing the advertised drugs more. Commercial bias-free educational programs can provide a good outlook on different options available for diseases.

Overtesting and unnecessary imaging is another core issue that needs attention.

Continuing education of the referring providers can reduce the unnecessary use of MRI scans for patients with osteoarthritis. Another important observation is that ordering radiographs as a gatekeeper study before DECT in gouty arthritis is non-beneficial since these do not detect radiopaque densities and cannot be used to prevent unnecessary DECT scans.

This review highlights that the overuse practices may have a rationale rooted in physiology, but continuing these practices without high-grade clinical evidence results in suboptimal clinical care. This analysis has some limitations. One limitation of our review is that we did not use a comprehensive grading system for the included articles. We did not employ any bias assessment tools for the included studies. We only reviewed articles with specific keywords related to medical overuse in rheumatology. We excluded articles without an abstract as well as studies related to orthopedic surgery and sports injuries. Hence, we might have missed some relevant studies. Another limitation is that we chose the articles published in 2018 only. The final selection of articles for this review was a subjective decision by the authors.

The ultimate goal of developing strategies to reduce overuse should be to focus on establishing practice guidelines based on high-quality evidence and re-examine the practices based on low-level evidence. However, this can be difficult to achieve in rheumatology, where the diseases have low prevalence.

Physician burnout in rheumatology can be associated with overtesting and overuse.

Burnout can affect the personal well-being of the physicians and, in turn adversely affect patients’ well-being³³. Physicians are being pushed to see more patients and take other non-clinical responsibilities. Inefficient EHR can add to the list of headaches for rheumatology practices. Decreasing the health insurance mandated metrics and other unnecessary documentation requirements will ultimately lead to more patient-centered care. Best clinical practice guidelines rooted in high-level evidence can result in both physician and patient satisfaction.