Unnecessary health care
The examples and perspective in this article may not represent a worldwide view of the subject. (May 2018) (Learn how and when to remove this template message)
Unnecessary health care (overutilization, overuse, or overtreatment) is healthcare provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its healthcare spending ($750 billion out of $2.6 trillion) in 2012.
Factors that drive overuse include paying healthcare providers more to do more (fee-for-service), defensive medicine to protect against litigiousness, and insulation from price sensitivity in instances where the consumer is not the payer—the patient receives goods and services but insurance pays for them (whether public insurance, private, or both). Such factors leave many actors in the system (doctors, patients, pharmaceutical companies, device manufacturers) with inadequate incentive to restrain health care prices or overuse. This drives payers, such as national health insurance systems or the U.S. Centers for Medicare and Medicaid Services, to focus on medical necessity as a condition for payment. However, the threshold between necessity and lack thereof can often be subjective.
Overtreatment, in the strict sense, may refer to unnecessary medical interventions, including treatment of a self-limited condition (overdiagnosis) or to extensive treatment for a condition that requires only limited treatment.
It is economicaly linked with overmedicalization.
- 1 Definition
- 2 Cost
- 3 Causes
- 4 Examples
- 5 Reduction efforts
- 6 See also
- 7 References
- 8 External links
A forerunner of the term was what Jack Wennberg called unwarranted variation, different rates of treatments based upon where people lived, not clinical rationale. He had discovered that in studies that began in 1967 and were published in the 1970s and the 1980s: "The basic premise - that medicine was driven by science and by physicians capable of making clinical decisions based on well-established fact and theory - was simply incompatible with the data we saw. It was immediately apparent that suppliers were more important in driving demand than had been previously realized."
In 2008, US bioethicist Ezekiel J. Emanuel and health economist Victor R. Fuchs defined unnecessary health care as "overutilization," healthcare provided with a higher volume or cost than is appropriate. Recently, economists have sought to understand unnecessary health care in terms of misconsumption rather than overconsumption.
In 2009 two US physicians wrote in an editorial, that unnecessary care was "defined as services which show no demonstrable benefit to patients" and might represent 30% of U.S. medical care. They referred to a 2003 study on regional variations in Medicare spending, which found, "Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions, but do not have better health outcomes or satisfaction with care."
In January 2012, the American College of Physicians Ethics, Professionalism, and Human Rights Committee suggested that overtreatment can also be understood in contrast to 'parsimonious care', defined as "care that utilizes the most efficient means to effectively diagnose a condition and treat a patient."
In April 2012, Berwick, from the Institute for Healthcare Improvement, and Andrew Hackbarth from the RAND Corporation defined overtreatment as "subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help them — care rooted in outmoded habits, supply-driven behaviors, and ignoring science." They wrote that trying to do something (treatment or testing) for all patients who might need it inevitably entails doing that same thing for some patients who might not need it." In uncertain situations, "some non-beneficial care was the necessary byproduct of optimal clinical decision making."
In October 2015, two pediatricians said that considering "overtreatment as an ethical violation" could help see the conflicting incentives of healthcare workers for treatment or nontreatment.
In the US, the country which spends the most on healthcare per person globally, patients have fewer doctor visits and fewer days in hospitals than people in other countries do, but prices are high, there is more use of some procedures and new drugs than elsewhere, and doctor salaries are double the levels in other countries. The New York Times reported "no one knows for sure" how much unnecessary care exists in the United States. Overuse of medical care is no longer a large fraction of total health care spending, which was $3.3 trillion in 2016.
Researchers in 2014 analyzed many services listed as low value by Choosing Wisely and other sources. They looked at spending in 2008-2009 and found that these services represented 0.6% or 2.7% of Medicare costs and there was no significant pattern of particular types of physicians ordering these low value services. The Institute of Medicine in 2010 gave two estimates of "unnecessary services," using different methodologies: 0.2% or 1% to 5% of health spending, which was US$2.6 trillion. The Institute of Medicine quoted that 2010 report in a 2012 report to support an estimate of 8% ($210 billion) in unnecessary services, without explaining the discrepancy. This IOM 2012 report also said there were $555 billion in other wasted spending, which have an "unknown overlap" with each other and the $210 billion.. The United States National Academy of Sciences estimated in 2005, without giving its methods or sources, that "between $.30 and $.40 of every dollar spent on healthcare is spent on the costs of poor quality," amounting to" slightly more than a half-trillion dollars a year... wasted on overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency. In 2003 Fisher et al.  found that there was "no apparent regional health benefit for Medicare recipients from doing more, whether 'more' is expressed as hospitalizations, surgical procedures, or consultations within the hospital." Up to 30% of Medicare spending could be cut in 2003 without harming patients.
Physicians' decisions are the proximate cause of unnecessary care, though the potential incentives and penalties they face can influence their choices.
Third-party payers and fee-for-service
When public or private insurance cover expenses and doctors are paid under a fee-for-service (FFS) model, neither has an incentive to consider the cost of treatment, a combination that contributes to waste. Fee-for-service is a large incentive for overuse because health care providers (such as doctors and hospitals) receive revenue from the overtreatment.
Atul Gawande investigated Medicare FFS reimbursements in McAllen, Texas, for a 2009 article in the New Yorker. In 2006, the town of McAllen was the second-most expensive Medicare market, behind Miami. Costs per beneficiary were almost twice the national average.
In 1992, however, McAllen had been almost exactly in line with the Medicare spending average. After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded the town was a chief example of the overuse of medical services. Gawande concluded that a business culture (physicians viewing their practices as a revenue stream) had established itself there, in contrast to a culture of low-cost high-quality medicine at the Mayo Clinic and in the Grand Junction, Colorado, market. Gawande advised:
As America struggles to extend healthcare coverage while curbing health care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don't, McAllen won't be an outlier. It will be our future.
Medical malpractice laws and defensive medicine
To protect themselves from legal prosecution U.S. physicians have an incentive to order clinically unnecessary tests or tests of little potential value. While defensive medicine is a favored explanation for high medical costs by physicians, Gawande estimated in 2010 it only contributed to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008.
Direct-to-consumer advertising can encourage patients to ask for drugs, devices, diagnostics, or procedures. Sometimes service providers will simply give these treatments or services rather than attempting the potentially more unpleasant task of convincing the patient what they have requested is not needed, or is likely to cause more harm than good.
- Attempting to mitigate a risk without considering how small or unlikely the potential benefit is
- Attempting to fix an underlying problem, instead of using a less-risky monitoring or coping strategy
- Acting too quickly, when waiting for more information might be wiser
- Acting without considering the benefits of doing nothing
- Discounting downsides of diagnostic testing
- Preferring newer over older treatments without considering the cost of new treatments or the effectiveness of older ones
- Treating patients with terminal illness to maximize life span over quality of life, without probing a patient's preferences
Overuse of diagnostic imaging, such as X-rays and CT scans, is defined as any application unlikely to improve patient care. Factors that contribute to overuse include "self-referral, patient wishes, inappropriate financially motivated factors, health system factors, industry, media, lack of awareness" and defensive medicine. Respected organizations—such as the American College of Radiology (ACR), Royal College of Radiologists (RCR) and the World Health Organization (WHO)—have developed "appropriateness criteria". The Canadian Association of Radiologists estimated in 2009 that 30% of imaging was unnecessary in the Canadian health care system. 2008 Medicare claims showed overuse with chest CT's. Financial incentives have also been shown to have a significant impact on dental X-ray use with dentists who are paid a separate fee for each X-ray providing more X-rays. 
One type of overuse can be physician self-referral. Multiple studies have replicated the finding that when non-radiologists have an ownership interest in the fees generated by radiology equipment—and can self-refer—their use of imaging is unnecessarily higher. The majority of U.S. growth in imaging use (the fastest-growing physician service) comes from self-referring nonradiologists. In 2004, this overuse was estimated to contribute to $16 billion of annual U.S. health care costs.
As of a 2018 review evidence of overtreatment overmedicalization, and overdiagnosis in Pediatrics have been use of commercial rehydration solution, antidepressants, and parenteral nutrition; overmedicalization with planned early deliveries, immobilization of ankle injuries, use of hydrolyzed infant formula; and overdiagnosis of hypoxemia among children recovering from bronchiolitis. 
- Hospitalizations for those with chronic conditions who could be treated as outpatients
- Surgeries in Medicare patients in their last year of life; regions with high levels had higher death rates
- Antibiotic use for viral or self-limiting infections (an overmedication that can promote antibiotic resistance)
- Opiate prescriptions carry the risk of addiction. In some cases, the number of pills prescribed might exceed what is actually needed for pain relief from a given condition, or a different pain management technique or medication would be effective but less risky.
- Many blood transfusions in the U.S. are given without checking to see if they are needed after a previous transfusion, or are given in cases where monitoring, recovering the patient's own blood, or iron therapy would be effective and reduce the risk of complications
- An estimated one in eight coronary stents (used in $20,000 procedures) with nonacute indications (U.S.)
- Heart bypass surgeries at Redding Medical Center which resulted in a FBI raid
- Screening patients with advanced cancer for other cancers
- Annual cervical cancer screening in women with medical histories of normal pap smear and HPV test results
Utilization management (utilization review) has evolved over decades among both public and private payers in an attempt to reduce overuse. In this effort, insurers employ physicians to review the actions of other physicians and detect overuse. Utilization review has a poor reputation among most clinicians as a corrupted system in which utilization reviewers have their own perverse incentives (i.e., find ways to deny coverage no matter what) and in some cases are not practicing physicians, lacking real-world clinical insight or wisdom.
The 2010 U.S. health care reform, the Patient Protection and Affordable Care Act, did not contain serious strategies to reduce overuse; "the public has made it clear that it does not want to be told what medical care it can and cannot have." Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization, you will be called a Nazi before the day is out".
Professional societies and other groups have begun to push for policy changes that would encourage clinicians to avoid providing unnecessary care. Most physicians accept that laboratory tests are overused, but "it remains difficult to persuade them to consider the possibility that they, too, might be overutilizing laboratory tests." In November 2011, the American Board of Internal Medicine Foundation began the Choosing Wisely campaign, which aims to raise awareness of overtreatment and change physician behavior by publicizing lists of tests and treatments that are often overused, and which doctors and patients should try to avoid.
In the UK, 2011, online platform AskMyGP was launched to decrease the amount of unnecessary medical appointments. In the app patients are given a questionnaire about their symptoms, which then assesses the patient's need for medical care. The program was a success, and as of January 2018 has managed over 29,000 patient episodes.
In April 2012, the Lown Institute and the New America Foundation Health Policy Program convened the 'Avoiding Avoidable Care' conference. It was the first major medical conference to focus entirely on overuse, and it included presentations from speakers including Bernard Lown, Don Berwick, Christine Cassel, Amitabh Chandra, JudyAnn Bigby, and Julio Frenk. A second meeting was planned for December 2013.
Since the meeting, the Lown Institute has focused its work on deepening the understanding of overuse and generating public discussion of the ethical and cultural drivers of overuse, especially on the role of the hidden curriculum in medical school and residency.
Consumer cost sharing
This section needs expansion. You can help by adding to it. (October 2011)
- Ezekiel J. Emanuel, Victor R. Fuchs (2008). "The perfect storm of overutilization" (PDF). The Journal of the American Medical Association. 299 (23): 2789–91. doi:10.1001/jama.299.23.2789. PMID 18560006. Archived from the original (PDF) on September 2, 2009.
- Kliff, Sarah (September 7, 2012). "We spend $750 billion on unnecessary health care. Two charts explain why". The Washington Post. Archived from the original on December 30, 2015. Retrieved March 31, 2016.
- Ezekiel J. Emanuel & Victor R. Fuchs (2008). "Health Care Overutilization in the United States—Reply". The Journal of the American Medical Association. 300 (19): 2251. doi:10.1001/jama.2008.605.
- Victor R. Fuchs (December 2009). "Eliminating 'waste' in health care". JAMA: The Journal of the American Medical Association. 302 (22): 2481–2482. doi:10.1001/jama.2009.1821. PMID 19996406.
- Alix Spiegel (November 10, 2009). "More is Less". This American Life. Archived from the original on November 5, 2011.
- Michael T. McCue Clamping down on variation Archived December 18, 2007, at the Wayback Machine - Managed Healthcare Executive, February 01, 2003
- Hensher, Martin; Tisdell, John; Zimitat, Craig (March 1, 2017). ""Too much medicine": Insights and explanations from economic theory and research". Social Science & Medicine. 176: 77–84. doi:10.1016/j.socscimed.2017.01.020. PMID 28131024.
- Reilly BM, Evans AT (2009). "Much ado about (doing) nothing". Ann Intern Med. 150 (4): 270–1. CiteSeerX 10.1.1.688.1277. doi:10.7326/0003-4819-150-4-200902170-00008. PMID 19221379. (subscription required)
- Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL (February 2003). "The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care". Ann. Intern. Med. 138 (4): 288–98. doi:10.7326/0003-4819-138-4-200302180-00007. PMID 12585826.CS1 maint: Multiple names: authors list (link)
- Snyder L (2012). "American College of Physicians Ethics Manual: sixth edition". Ann Intern Med. 156 (1 Pt 2): 73–104. doi:10.7326/0003-4819-156-1-201201031-00001. PMID 22213573.
- Berwick DM, Hackbarth AD. Eliminating waste in US health care.JAMA. 2012 Apr 11;307(14):1513-6. doi:10.1001/jama.2012.362. (subscription required)
- Ralston Shawn L., Schroeder Alan R. (2015). "Doing More vs Doing Good: Aligning Our Ethical Principles From the Personal to the Societal". JAMA Pediatrics. 169 (12): 1085–6. doi:10.1001/jamapediatrics.2015.2702. PMID 26502277. Archived from the original on April 20, 2016. (subscription required)
- Kliff, Sarah (October 16, 2017). "The problem is the prices". Retrieved December 7, 2018.
- "Spending, Use of Services, Prices, and Health in 13 Countries". www.commonwealthfund.org. Retrieved December 7, 2018.
- Gina Colata (March 29, 2010). "Law May Do Little to Help Curb Unnecessary Care". The New York Times. Archived from the original on July 16, 2017.
- "Table 1 National Health Expenditures". www.cms.gov. Retrieved December 5, 2018.
- McWilliams, J. Michael; Chernew, Michael E.; Elshaug, Adam G.; Landon, Bruce E.; Schwartz, Aaron L. (July 1, 2014). "Measuring Low-Value Care in Medicare". JAMA Internal Medicine. 174 (7): 1067–1076. doi:10.1001/jamainternmed.2014.1541. ISSN 2168-6106. PMC 4241845. PMID 24819824.
- McWilliams, J. Michael; Zaslavsky, Alan M.; Jena, Anupam B.; Schwartz, Aaron L. (December 3, 2018). "Analysis of Physician Variation in Provision of Low-Value Services". JAMA Internal Medicine. 179 (1): 16–25. doi:10.1001/jamainternmed.2018.5086. PMID 30508010.
- Institute of Medicine (2010). "The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary". National Academies Press, (their $5 billion figure was 0.2% of total health expenditure). Retrieved December 7, 2018.
- Loukopoulos, T.; Ahmad, I. (2000). "Replicating the contents of a WWW multimedia repository to minimize download time". Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. The National Academies Press. pp. 101–102. doi:10.1109/ipdps.2000.846027. ISBN 978-0-309-26073-2.
- Lawrence, David (2005). Building a Better Delivery System: A New Engineering/Health Care Partnership – Bridging the Quality Chasm. Washington, DC: National Academy of Sciences. p. 99. ISBN 978-0-309-65406-7. Archived from the original on July 9, 2008.
- Elliott S. Fisher, David E. Wennberg, Thérèse A. Stukel, Daniel J. Gottlieb, F. L. Lucas & Etoile L. Pinder (February 2003). "The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care". Annals of Internal Medicine. 138 (4): 273–287. doi:10.7326/0003-4819-138-4-200302180-00006. PMID 12585825. Archived from the original on January 2, 2011.CS1 maint: Multiple names: authors list (link)
- Elliott S. Fisher, David E. Wennberg, Therese A. Stukel, Daniel J. Gottlieb, F. L. Lucas & Etoile L. Pinder (February 2003). "The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care". Annals of Internal Medicine. 138 (4): 288–298. doi:10.7326/0003-4819-138-4-200302180-00007. PMID 12585826. Archived from the original on June 30, 2011.CS1 maint: Multiple names: authors list (link)
- Steven A. Schroeder (April 2011). "Personal reflections on the high cost of American medical care: Many causes but few politically sustainable solutions". Archives of Internal Medicine. 171 (8): 722–727. doi:10.1001/archinternmed.2011.149. PMID 21518938.
- "Medicare Options In Biden Budget Talks Get Boost". NPR. The Associated Press. June 15, 2011. Retrieved June 26, 2011.
- Gibson; Singh, Rosemary (2010). The Treatment Trap: How the Overuse of Medical Care is Wrecking Your Health. Chicago: Ivan R. Dee. pp. 63–83. ISBN 9781566638425. Archived from the original on July 5, 2013.
- Katty Kay (July 7, 2009). "Texas town's healthcare puzzle". BBC News. Archived from the original on February 16, 2010. Retrieved June 19, 2011.
- Bryant Furlow (October 2009). "US reimbursement systems encourage fraud and overutilisation". The Lancet Oncology. 10 (10): 937–938. doi:10.1016/S1470-2045(09)70297-9. PMID 19810157.
- Atul Gawande (June 1, 2009). "The Cost Conundrum – What a Texas town can teach us about health care". The New Yorker. Archived from the original on June 10, 2011. Retrieved June 29, 2011.
- "Spend More, Get Less? The Health Care 'Conundrum'". Fresh Air. NPR. June 17, 2009. Archived from the original on March 28, 2014. Retrieved June 29, 2011.
- Michelle M. Mello, Amitabh Chandra, Atul A. Gawande & David M. Studdert (September 2010). "National costs of the medical liability system". Health Affairs (Project Hope). 29 (9): 1569–1577. doi:10.1377/hlthaff.2009.0807. PMC 3048809. PMID 20820010.CS1 maint: Multiple names: authors list (link)
- Gilbert Welch Assumptions That Drive Too Much Medical Care American College of Physicians, n.d., retrieved 9 May 2018
- Gilbert Welch (2016). Less Medicine, More Health. Beacon Press. ISBN 978-0807077580.
- B. Rehani (January 2011). "Imaging overutilisation: Is enough being done globally?". Biomedical Imaging and Intervention Journal. 7 (1): e6. doi:10.2349/biij.7.1.e6 (inactive March 16, 2019). PMC 3107688. PMID 21655115.
- "Do you need that scan?" (PDF). Canadian Association of Radiologists. 2009. Archived from the original (PDF) on March 22, 2011. Retrieved June 27, 2011.
- Walt Bogdanich; Jo Craven McGinty (June 17, 2011). "Medicare Claims Show Overuse for CT Scanning". The New York Times. Archived from the original on June 22, 2011. Retrieved June 22, 2011.
- Chalkley, M.; Listl, S. (December 30, 2017). "First do no harm – The impact of financial incentives on dental X-rays". Journal of Health Economics. 58 (March 2018): 1–9. doi:10.1016/j.jhealeco.2017.12.005. PMID 29408150.
- Elm Ho (July 2010). "Overuse, overdose, overdiagnosis... overreaction?". Biomedical Imaging and Intervention Journal. 6 (3): e8. doi:10.2349/biij.6.3.e8. PMC 3097773. PMID 21611049.
- David C. Levin & Vijay M. Rao (March 2004). "Turf wars in radiology: the overutilization of imaging resulting from self-referral". Journal of the American College of Radiology : JACR. 1 (3): 169–172. doi:10.1016/j.jacr.2003.12.009. PMID 17411553.
- 2017 Update on Pediatric Medical Overuse. A Review. JAMA Pediatr. 2018;172(5):482-486. doi:10.1001/jamapediatrics.2017.5752
- James CD, Hanson K, Solon O, Whitty CJ, Peabody J (June 2011). "Do doctors under-provide, over-provide or do both? Exploring the quality of medical treatment in the Philippines". International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua. 23 (4): 445–55. doi:10.1093/intqhc/mzr029. PMC 3136200. PMID 21672923.
- "Effective Care – A Dartmouth Atlas Project Topic Brief" (PDF). Dartmouth Atlas Project. January 15, 2007. Archived (PDF) from the original on October 2, 2011. Retrieved June 29, 2011.
- Carrie Gann (October 6, 2011). "Medicare Patients Get Costly Surgery Before Death". ABC News. Retrieved October 6, 2011.
- Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK (2011). "The intensity and variation of surgical care at the end of life: a retrospective cohort study". The Lancet. 378 (9800): 1408–1413. doi:10.1016/S0140-6736(11)61268-3. PMID 21982520.
- Malika Taufiq & Rukhsana W. Zuberi (January 2011). "Overuse of antibiotics in children for upper respiratory infections (URIs): a dilemma". Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 21 (1): 60. PMID 21276393.
- Markus Dietl & Dieter Korczak (2011). "Over-, under- and misuse of pain treatment in Germany". GMS health technology assessment. 7: Doc03. doi:10.3205/hta000094. PMC 3080661. PMID 21522485.
- Ryan Jaslow (June 28, 2011) Blood transfusion regulations needed to rein in overuse: Panel Archived November 4, 2012, at the Wayback Machine CBS News/Associated Press. Accessed June 28, 2011.
- Ron Winslow; John Carreyrou (July 6, 2011). "Heart Treatment Overused – Study Finds Doctors Often Too Quick to Try Costly Procedures to Clear Arteries". The Wall Street Journal. Archived from the original on July 17, 2015. Retrieved July 6, 2011.
- Chan; et al. (2011). "Appropriateness of Percutaneous Coronary Intervention". JAMA. 306 (1): 53–61. doi:10.1001/jama.2011.916. PMC 3293218. PMID 21730241.
- Jay Hancock (July 18, 2011). Progress, but not enough, against needless hospital procedures Archived September 20, 2011, at the Wayback Machine The Baltimore Sun Accessed August 4, 2011.
- Final Decision and Order Archived September 30, 2011, at the Wayback Machine Maryland State Board of Physicians Accessed August 4, 2011.
- Meredith Cohn (July 29, 2011). St. Joseph Medical Center's CEO resigns Archived September 29, 2012, at the Wayback Machine The Baltimore Sun Accessed August 4, 2011.
- Larry Husten (July 13, 2011). Maryland Revokes Mark Midei’s Medical License Archived July 16, 2011, at the Wayback Machine Forbes Accessed August 4, 2011.
- Walshe K, Shortell SM (2004). "When things go wrong: how health care organizations deal with major failures". Health Aff (Millwood). 23 (3): 103–11. doi:10.1377/hlthaff.23.3.103. PMID 15160808.
- Gilbert M. Gaul (July 25, 2005). "At California Hospital, Red Flags and an FBI Raid". The Washington Post. Archived from the original on November 10, 2012. Retrieved July 5, 2011.
- Rosemary Gibson (August 25, 2010). "Can Funders Quell a 'Perfect Storm of Overutilization'?". Health Affairs. Archived from the original on May 19, 2011. Retrieved July 5, 2010.
- Camelia S. Sima; Katherine S. Panageas; Deborah Schrag (October 2010). "Cancer screening among patients with advanced cancer". JAMA. 304 (14): 1584–1591. doi:10.1001/jama.2010.1449. PMC 3728828. PMID 20940384.
- Roland KB, Soman A, Bernard VB, et al. (2011). "Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States". American Journal of Obstetrics and Gynecology. 205 (5): 447.e1–8. doi:10.1016/j.ajog.2011.06.001. PMID 21840492.
- Kathleen Doheny (August 20, 2011). "Annual Pap tests often ordered but unneeded Archived March 20, 2012, at the Wayback Machine" HealthDay (USA Today). Accessed August 22, 2011.
- Jamie A. Weydert, Newell D. Nobbs, Ronald Feld & John D. Kemp (September 2005). "A simple, focused, computerized query to detect overutilization of laboratory tests". Archives of Pathology & Laboratory Medicine. 129 (9): 1141–1143. doi:10.1043/1543-2165(2005)129[1141:ASFCQT]2.0.CO;2 (inactive March 16, 2019). PMID 16119987.CS1 maint: Multiple names: authors list (link)
- "Avoiding Avoidable Care". avoidablecare.org. Archived from the original on January 3, 2015. Retrieved January 19, 2015.
- Harvard Kennedy School. "Harvard Kennedy School - Amitabh Chandra". harvard.edu. Archived from the original on January 11, 2015. Retrieved January 19, 2015.
- "Featured Speakers | Avoiding Avoidable Care". Archived from the original on August 14, 2013. Retrieved August 21, 2013.
- "2013 Lown Conference: From Avoidable Care to Right Care". Lown Institute. Archived from the original on November 4, 2013. Retrieved August 21, 2013.
- Zapata Josué A., Lai Andrew R., Moriates Christopher (2017). "Is Excessive Resource Utilization an Adverse Event?". JAMA. 317 (8): 849–850. doi:10.1001/jama.2017.0698. PMID 28245327.CS1 maint: Multiple names: authors list (link)
- Brownlee, Shannon (2007). Overtreated: Why too much medicine is making us sicker and poorer. London: Bloomsbury. ISBN 978-1-58234-580-2.
- Gawande, Atul (May 11, 2015). "America's Epidemic of Unnecessary Care". newyorker.com. Retrieved May 4, 2015.
- Hendee WR, Becker GJ, Borgstede JP, et al. (October 2010). "Addressing overutilization in medical imaging". Radiology. 257 (1): 240–5. doi:10.1148/radiol.10100063. PMID 20736333.
- R. E. Malone (October 1998). "Whither the almshouse? Overutilization and the role of the emergency department". Journal of Health Politics, Policy and Law. 23 (5): 795–832. doi:10.1215/03616878-23-5-795. PMID 9803363.
- Sana M. Al-Khatib, Anne Hellkamp, Jeptha Curtis, Daniel Mark, Eric Peterson, Gillian D. Sanders, Paul A. Heidenreich, Adrian F. Hernandez, Lesley H. Curtis & Stephen Hammill (January 2011). "Non-evidence-based ICD implantations in the United States". JAMA: The Journal of the American Medical Association. 305 (1): 43–49. doi:10.1001/jama.2010.1915. PMC 3432303. PMID 21205965.CS1 maint: Multiple names: authors list (link)
- David B. Larson, Lara W. Johnson, Beverly M. Schnell, Shelia R. Salisbury & Howard P. Forman (January 2011). "National trends in CT use in the emergency department: 1995–2007". Radiology. 258 (1): 164–173. doi:10.1148/radiol.10100640. PMID 21115875.CS1 maint: Multiple names: authors list (link) – a story on the study
- Gawande, Atul A.; Colla, Carrie H.; Halpern, Scott D.; Landon, Bruce E. (April 3, 2014). "Avoiding Low-Value Care". New England Journal of Medicine. 370 (14): e21. doi:10.1056/NEJMp1401245. PMID 24693918.
- Disease Creep: How we're fooled into using more medicine than we need by medical investigative journalist Jeanne Lenzer