"Less is More" Series Highlights Overused Medical Interventions

May 12, 2010

The prominent medical journal Archives of Internal Medicine has launched a new feature, “Less is More,” intended to “highlight situations in which the overuse of medical care may result in harm and in which less care is likely to result in better health.” As a freely available editorial in the current issue explains:

Across the United States, the rate of use of common medical services varies markedly, but measures of health are not better in areas where more services are provided. In fact, the opposite is true—some measures of health are worse in areas where people receive more health services.

This concept will not be unfamiliar to readers who have followed our discussions about screening mammography, continuous electronic fetal monitoring, hormone therapy, and other concerns. The Archives editorial also uses postmenopausal hormone therapy as an example of a case in which “harms have been proven to outweigh benefits.”

The current issue’s articles on this concept are focused on proton pump inhibitors (PPIs), a class of drugs used for conditions such as acid reflux and ulcers, and for which 113.4 million prescriptions are apparently filled each year. The articles, and a related editorial, discuss potential increased risk of Clostridium difficile and pneumonia infections associated with the drugs, as well as potential risks for an increased rate of spine, lower arm, and total fractures in postmenopausal women. As the PPI-focused editorial concludes:

The problem with this paradigm is that for most patients the adverse effects of PPIs outweigh the benefits. Reducing the unnecessary use of these medications will require action by both physicians and patients. As physicians, we should offer treatments other than PPIs for functional dyspepsia, prescribe short courses of PPI treatment (after disclosure of possible risks and benefits), and consider a trial of discontinuing PPI therapy in patients who are asymptomatic. Once our patients fully appreciate the adverse effects of PPIs, they themselves may prefer other treatments, including tincture of time (many cases of dyspepsia resolve on their own), behavioral changes (eg, eating smaller meals [especially before bed], weight loss, smoking cessation, stress reduction), and other nonmedical interventions (eg, raising the head of their bed).

On a broader level, the over prescription of PPIs should also remind us to critically evaluate our own treatment paradigms: “more is better” or “do no harm”?

While the “Less is More” editorial launching the series is freely available, other relevant articles in the series may be available to subscribers only. You can use this tool to find libraries near you that have this journal, or check with your local library about access to specific articles.

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