Musculoskeletal healthcare: Have we over‐egged the pudding?

Abstract

The phrase “to over-egg the pudding” is a terrific analogy for what is now increasingly common in health care: medical overuse. Cooks would know that if you skimp with the eggs a pudding won't hold together and if you use too many eggs the pudding will go rubbery. And in musculoskeletal health care we also need to get the balance right. People's health can suffer when they receive too little health care and also if they receive too much health care. The problem of too little health care is well recognized and it is easy to understand that patients’ health can be put at risk by underuse of proven healthcare services. However, the opposite problem is also possible but is less well recognized.1 In this editorial we adopt some perspectives from the field of overdiagnosis to consider overuse in musculoskeletal health care. We provide some examples that illustrate the nature and size of the problem,3 and highlight potential drivers of overuse of musculoskelatal health services (Table 1). Overtesting Ordering unnecessary tests Overdetection Clinicians act upon clinically unimportant findings Overdefinition Changed disease boundaries encourage more health care Overtreatment Culture, industry and health systems encourage treatment that does not provide a net benefit A common starting point for overdiagnosis in musculoskeletal health care is overtesting; where patients receive unnecessary tests. A good example is the uncritical interpretation of red flags to screen for serious pathology. Some texts and guidelines inadvertently encourage medical overuse by offering a long list of red flags and encouraging diagnostic work-up and/or specialist referral if even a single red flag is positive. One study in Australian general practice found that of 1172 consecutive patients with back pain, 80% recorded a +ve response to at least 1 of the 25 red flags that were considered by the study general practitionerss.4 The irony here is that even though the clinicians were acting in good faith and aiming to help their patients, they may have harmed them through overdiagnosis. Other examples in musculoskeletal health care include repeat vitamin D testing; in Australia Medical Benefits Scheme costs for vitamin D testing rose from $109.0 million in the 2009-2010 financial year to $151.1 million in 2012-2013.5 In the sports medicine field it is common to hear of professional athletes who have sustained an acute hamstring muscle strain injury undergoing magnetic resonance imaging to guide management and predict return to sport, but neither is supported by robust evidence.6 The concern here is the possibility this practice leak may leak out into the wider community. In the overdiagnosis literature overdetection refers to the identification of abnormalities that resolve spontaneously or would not progress sufficiently to cause symptoms or harm during a person's lifetime.7 In the musculoskeletal field most incidental findings are picked up by overtesting in people with symptoms; using tests that commonly yield positive test findings in asymptomatic people. The challenge is then determining if the finding is relevant or not. A good example of medical overuse driven by overdetection would be acting upon the incidental findings commonly found with musculoskeletal imaging (eg lumbar disc degeneration, rotator cuff tear, femoroacetabular impingement, heel spur) and initiating more intensive treatment for the patient (eg specialist referral, surgery). What compounds the problem is that many of the surgeries that are encouraged (eg knee arthroscopy,8 subacromial decompression9) are now known to be no more effective than placebo. In all these cases the medical overuse is triggered by an unwarranted diagnosis. Overdetection is not confined to the tests that would typically be considered the domain of the medical profession. In physiotherapy, podiatry and chiropractic, the treatments that characterize these professions are primarily driven by assessment of factors such as