Medicine:Unnecessary surgery

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Short description: Operations performed without clear medical necessity

Unnecessary surgery refers to operative procedures performed without adequate clinical indication or expected net benefit for the patient, relative to less invasive or non-operative alternatives. The concept overlaps with medical overuse, low-value care, and defensive medicine, and is studied through evidence syntheses, practice-variation research, and evaluations of appropriateness criteria.[1][2]

Background

Concerns about avoidable operations intensified with the rise of evidence-based medicine and studies documenting large geographic variations in procedure rates that could not be explained by patient need.[3][4] The Institute of Medicine highlighted waste from unnecessary services as a major quality and cost problem in the United States.[5][6] Internationally, the BMJ's Too much medicine initiative and the ABIM Foundation's Choosing Wisely campaign have sought to identify and reduce low-value interventions, including operations.[7][8] The OECD has likewise called out wasteful spending related to overuse, including surgical care.[9]

Drivers

There are multiple, interacting causes of unnecessary surgery. Practice variation and local medical culture (so-called "preference-sensitive" care) can lead to different procedure rates in different areas even when patient needs are similar. Studies and policy analyses have documented how local norms and clinician practices influence whether surgery is recommended or pursued.[10][11]

Defensive medicine driven by malpractice concerns can increase procedure use, as clinicians sometimes recommend interventions primarily to reduce perceived legal risk rather than because surgery is clearly indicated; national surveys and research have explored clinicians' views on defensive practices and their cost impacts.[12][13]

Financial incentives in fee-for-service settings and supply-sensitive care, where greater local capacity correlates with higher use, can also drive unnecessary operations; health-economics analyses and OECD reports document how payment systems and resource availability affect utilization patterns.[9]

Diagnostic uncertainty, limited shared decision-making, and outdated or contradicted practices (so-called "medical reversal") further contribute to unnecessary procedures when clinicians and patients lack clear, evidence-based guidance and when historical practice persists despite newer evidence showing lack of benefit.[14]

Prevalence and variation

Rates of common operations vary several-fold between regions and hospitals, even after adjusting for demographics. For example, Tonsillectomy in children showed a seven-fold variation across English local authorities in 2000–2005, illustrating the scale of geographic differences in some elective procedures.[15]

Hysterectomy for benign disease exhibits substantial small-area variation that has been documented in multiple countries and U.S. states, indicating that practice patterns and local factors affect the use of major gynecologic surgery.[16][17]

The Dartmouth Atlas and related atlases describe such differences as "unwarranted variation" when not explained by illness, patient preferences, or robust evidence.[18][19]

Examples debated in the literature

Arthroscopic knee surgery for osteoarthritis and degenerative meniscal tears has been debated because a sham-controlled trial found no better pain or function outcomes than placebo surgery, leading to reconsideration of its routine use for some patients.[20]

Percutaneous coronary intervention (PCI) for stable coronary disease is another example under debate: the COURAGE trial showed no reduction in death or myocardial infarction versus optimal medical therapy, prompting calls to curb inappropriate elective PCI and to align indications with evidence and patient preference.[21]

Cesarean section overuse has been highlighted by WHO statements emphasizing that cesareans should be performed when medically indicated; population rates above approximately 10% are not associated with further mortality reductions, prompting scrutiny of rising cesarean rates in many regions.[22][23][24]

Unnecessary operations raise questions of informed consent, conflicts of interest, and potential health fraud. U.S. Senate investigators have reported patterns of questionable cardiac procedures and financial incentives that may encourage overuse in certain settings.[25] News coverage has documented disciplinary actions for physicians who implanted unnecessary cardiac stents, illustrating harms to patients and erosion of trust.[26]

Responses and reduction strategies

Appropriateness criteria and clinical guidelines that prioritize non-operative care when supported by evidence, and "do-not-do" recommendations from professional bodies and health agencies, are commonly promoted to reduce unnecessary surgery and encourage practice aligned with current evidence.[8][9]

Shared decision-making for preference-sensitive care, supported by patient decision aids to align care with patient values and reduce unwarranted variation, is another key strategy that aims to ensure patients receive care that reflects their informed preferences and the best available evidence.[11]

Second-opinion programs, which have been used since the 1970s to vet recommendations for elective surgery and may avert inappropriate operations, are implemented in some systems and insurers to provide additional clinical review prior to major procedures.[27][28][29]

Safety checklists and perioperative pathways to curb non-indicated add-on procedures and improve reliability have been widely adopted; for example, the WHO surgical safety checklist has reduced complications in multiple settings, although its direct effects on procedure volumes vary by context and implementation.[30][31]

See also

References

  1. ↑ Korenstein, D; Choi, Y; Dressler, R; Finke, B; Tapper, S (23 January 2012). "Overuse of Health Care Services in the United States: An Understudied Problem". Archives of Internal Medicine (American Medical Association) 172 (2): 171–178. doi:10.1001/archinternmed.2011.772. PMID 22271125. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108760. Retrieved 14 October 2025. 
  2. ↑ Prasad, Vinay; Vandross, Andrae; Toomey, Caitlin; Cheung, Michael; Rho, Jason; Quinn, Steven; Chacko, Satish Jacob; Borkar, Durga et al. (18 July 2013). "A decade of reversal: an analysis of 146 contradicted medical practices". Mayo Clinic Proceedings (Elsevier) 88 (8): 790–798. doi:10.1016/j.mayocp.2013.05.012. PMID 23871230. 
  3. ↑ "The Dartmouth Atlas of Health Care". The Trustees of Dartmouth College. https://www.dartmouthatlas.org/. 
  4. ↑ Bronner, K. K. (2022). "The Dartmouth Atlas of Health Care". Research in Health Services & Regions (National Institutes of Health) 1 (1): 6. doi:10.1007/s43999-022-00006-2. PMID 39177806. 
  5. ↑ Smith, Mark (10 May 2013). "Best Care at Lower Cost". National Academies. https://www.ncbi.nlm.nih.gov/books/NBK207225/. 
  6. ↑ "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America". Institute of Medicine. 2013. https://professionalismandvalue.org/wp-content/uploads/2021/02/Better_Care_at_Lower_Cost_The_Path_to_Continuously_Learning_Health_Care_in_America.pdf. 
  7. ↑ "Too much medicine". BMJ Publishing Group. https://www.bmj.com/campaign/too-much-medicine. 
  8. ↑ 8.0 8.1 "Choosing Wisely". https://www.choosingwisely.org/. 
  9. ↑ 9.0 9.1 9.2 Tackling Wasteful Spending on Health. Paris: OECD Publishing. 2017. ISBN 978-92-64-26641-4. https://www.oecd.org/health/tackling-wasteful-spending-on-health-9789264266414-en.htm. Retrieved 14 October 2025. 
  10. ↑ "Introduction". The Dartmouth Atlas of Health Care in the United States. National Institutes of Health. December 1996. https://www.ncbi.nlm.nih.gov/books/NBK585008/. Retrieved 14 October 2025. 
  11. ↑ 11.0 11.1 "Preference-Sensitive Care". The Trustees of Dartmouth College. https://data.dartmouthatlas.org/downloads/reports/preference_sensitive.pdf. 
  12. ↑ Bishop, Thomas F.; Courtney, Patti M.; Dubois, Robert W. (2010). "Physicians' Views on Defensive Medicine: A National Survey". Archives of Internal Medicine (American Medical Association) 170 (12): 1081–1083. doi:10.1001/archinternmed.2010.135. PMID 20585077. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/416067. Retrieved 14 October 2025. 
  13. ↑ Rothberg, Michael B.; Stahl, Jonathan E.; Vijayaraghavan, T. V.; Sepucha, Karen; Fagerlin, Angela (2014). "The Cost of Defensive Medicine on 3 Hospital Medicine Services". JAMA Internal Medicine (American Medical Association) 174 (11): 1867–1868. doi:10.1001/jamainternmed.2014.4649. PMID 25222939. 
  14. ↑ Prasad, Vinay; Cifu, Adam (2013). "A decade of reversal: an analysis of 146 contradicted medical practices". Mayo Clinic Proceedings (Elsevier) 88 (8): 790–798. doi:10.1016/j.mayocp.2013.05.012. PMID 23871230. 
  15. ↑ Suleman, M; Clark, M. P. A.; Goldacre, M; Burton, M (April 2010). "Exploring the variation in paediatric tonsillectomy rates between English regions: a 5-year NHS and independent sector data analysis". Clinical Otolaryngology (John Wiley & Sons) 35 (2): 111–117. doi:10.1111/j.1749-4486.2010.02086.x. PMID 20500580. 
  16. ↑ Stoller, Nicole; Burnand, Bernard; Clifford, Barbara K.; González, Alexander; Eggli, Yves (19 May 2020). "Regional variation of hysterectomy for benign uterine diseases in Switzerland". PLOS ONE (PLOS) 15 (5). doi:10.1371/journal.pone.0233082. PMID 32407404. Bibcode: 2020PLoSO..1533082S. 
  17. ↑ Doll, K. M.; Goff, B. A. (2016). "Trends in Inpatient and Outpatient Hysterectomy and Oophorectomy". JAMA Surgery (American Medical Association) 151 (9). doi:10.1001/jamasurg.2016.0935. https://jamanetwork.com/journals/jamasurgery/fullarticle/2519878. Retrieved 14 October 2025. 
  18. ↑ "The Problem of Unwanted Variations". The Problem of Unwanted Variations - The Dartmouth Atlas of Health Care. National Institutes of Health. December 2000. https://www.ncbi.nlm.nih.gov/books/NBK588038/. Retrieved 14 October 2025. 
  19. ↑ "Variation in Care of Surgical Conditions". The Trustees of Dartmouth College. https://data.dartmouthatlas.org/downloads/atlases/Surgical_Atlas_2014.pdf. 
  20. ↑ Moseley, J. Bruce; O'Malley, Kathleen; Peterson, Mark; Menke, Thomas; Brody, Barbara (11 July 2002). "A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee". The New England Journal of Medicine (Massachusetts Medical Society) 347 (2): 81–88. doi:10.1056/NEJMoa013259. PMID 12110735. 
  21. ↑ Boden, William E.; O'Rourke, Robert A.; Teo, Koon K.; Hartigan, Paul M.; Maron, David J.; Kostuk, William J.; Norrie, William; Damberger, William et al. (12 April 2007). "Optimal Medical Therapy with or without PCI for Stable Coronary Disease". The New England Journal of Medicine (Massachusetts Medical Society) 356 (15): 1503–1516. doi:10.1056/NEJMoa070829. PMID 17387127. 
  22. ↑ Betrán, Ana Pilar; Torloni, Maria Regina; Zhang, Jun; Gülmezoglu, A. Metin (2016). "WHO Statement on Caesarean Section Rates". BJOG: An International Journal of Obstetrics and Gynaecology (John Wiley & Sons) 123 (5): 667–670. doi:10.1111/1471-0528.13526. PMID 26681211. 
  23. ↑ "Caesarean sections should only be performed when medically necessary, says WHO". World Health Organization. 9 April 2015. https://www.who.int/news/item/09-04-2015-caesarean-sections-should-only-be-performed-when-medically-necessary-says-who. 
  24. ↑ "WHO Statement on Caesarean Section Rates - Frequently Asked Questions". 9 June 2021. https://www.who.int/news-room/questions-and-answers/item/who-statement-on-caesarean-section-rates-frequently-asked-questions. 
  25. ↑ "Critical Condition: The Cardiac Surgery Industry in the United States". U.S. Senate. 2014. https://www.finance.senate.gov/imo/media/doc/101514%20Staff%20Report%20Critical%20Condition-The%20Cardiac%20Surgery%20Industry%20in%20the%20United%20States1.pdf. 
  26. ↑ Shaver, Katherine (19 March 2014). "St. Joseph cardiologist Mark Midei loses appeal; board revokes his medical license". The Washington Post (Nash Holdings). https://www.washingtonpost.com/local/st-joseph-cardiologist-mark-midei-loses-appeal-board-revokes-his-medical-license/2014/03/19/ba64b2be-af3d-11e3-95e8-39bef8e9a48b_story.html. 
  27. ↑ Flynn, Kathryn E.; Smith, M. A.; Vanness, David (2002). "From Physician to Consumer: The Effectiveness of Strategies to Manage Patient Demand for Medical Services". Medical Care Research and Review (SAGE Publications) 59 (3): 293–318. doi:10.1177/1077558702059003004. PMID 12205830. 
  28. ↑ Graboys, Thomas B.; Biegelsen, Beth; Lampert, Steven; Blatt, Charles M.; Lown, Bernard (1992). "Results of a Second-Opinion Trial Among Patients Recommended for Coronary Angiography". JAMA (American Medical Association) 268 (18): 2537–2540. doi:10.1001/jama.1992.03490180069028. PMID 1404821. https://jamanetwork.com/journals/jama/articlepdf/401120/jama_268_18_028.pdf?resultClick=1. Retrieved 14 October 2025. 
  29. ↑ "Medicare Second Surgical Opinion Programs". Centers for Medicare & Medicaid Services. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/HealthCareFinancingReview/Downloads/CMS1190360DL.pdf. 
  30. ↑ Haynes, Atul A.; Weiser, Thomas G.; Berry, William R.; Lipsitz, Stacey R.; Breizat, Abul N.; Dellinger, Eric P.; Dziekan, Grzegorz; Herfarth, Karl et al. (29 January 2009). "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population". The New England Journal of Medicine (Massachusetts Medical Society) 360 (5): 491–499. doi:10.1056/NEJMsa0810119. PMID 19144931. 
  31. ↑ Urbach, David R.; Dimick, Justin B.; Hayes, Kevin (2014). "Introduction of Surgical Safety Checklists in Ontario, Canada". The New England Journal of Medicine (Massachusetts Medical Society) 370 (11): 1029–1038. doi:10.1056/NEJMsa1308261. PMID 24620866. https://www.nejm.org/doi/full/10.1056/NEJMsa1308261. Retrieved 14 October 2025. 



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