Table 2:

Underused clinical practices^*

Care subcategory	Clinical practice	Disease or condition	No. of studies (No. of findings)	Percentage or range of underuse
Diagnostics
Laboratory test	Albumin-to-creatinine ratio	Diabetes mellitus,29^–32 chronic kidney disease31^,33	5 (7)	26.4–81.6
	Urine collection (24 h)	Kidney stone disease34	1 (1)	64.5
	Urine protein	Diabetes mellitus35	1 (1)	26.0
	Sputum sample	COPD36	1 (1)	97.0
	Oncotype dx prognostic tool	Breast cancer37	1 (1)	7.0
Referral	Secondary prevention stroke clinic	CVD38^–40	3 (3)	31.0–45.7
	Dietician or weight loss program	CVD31	1 (1)	81.8
	Smoking cessation program	CVD31	1 (1)	92.3
	Radiation oncologist	Prostate cancer41^,42	2 (2)	20.6–57.0
	Alcohol dependence resource	Alcohol addiction43	1 (1)	55.0
	Orthopedic pediatric clinic^†	Adolescent idiopathic scoliosis44	1 (1)	17.4
	Nephrology specialist	Chronic kidney disease45	1 (1)	55.3
	Pulmonary rehabilitation program	COPD46	1 (1)	34.2
Assessment	Eye examination	Diabetes mellitus29^,30^,32^,35^,47^–50	8 (8)	22.9–80.5
	Blood pressure	Diabetes mellitus,29^,30^,32^,47 chronic kidney disease,33 CVD,31 cardiac rehabilitation51	7 (8)	1.9–92.7
	Electrocardiogram^†	Diabetes mellitus,29^,30^,50 COPD,36 CVD31	5 (5)	3.6–78.8
	Foot examination	Diabetes mellitus30^,32^,35^,52	4 (4)	49.0–84.1
	Body mass index	Diabetes mellitus,29^,47 cardiac rehabilitation51	3 (3)	12.2–65.8
	Neuropathy	Diabetes mellitus29^,30^,47	3 (3)	81.9–89.7
	Waist circumference	Diabetes mellitus,29 CVD,31 elevated cardiometabolic risk52	3 (3)	53.0–91.3
	Diabetes (6-mo visit)	Diabetes mellitus32	1 (1)	36.3
	Swallowing	CVD38^,40^,53	3 (3)	35.2–50.5
	Well baby visit (at 18 mo)	Well baby visit54	1 (1)	61.8
	Asthma control	Asthma55	1 (2)	95.0–100.0
	Chronic stable angina	Breast cancer56	1 (1)	32.8
	COPD	Breast cancer56	1 (1)	33.7
	Congestive heart failure	Breast cancer56	1 (1)	26.7
	Transient ischemic attack	Breast cancer56	1 (1)	28.5
	Diabetes	Breast cancer survivors56	1 (1)	19.1
	Anesthesia preassessment	Colorectal surgery57	1 (1)	22.6
	Fracture risk assessment	Fragility fractures58	1 (1)	22.9
	Bowel function	Prostate cancer59	1 (1)	41.5
	Digital rectal examination	Prostate cancer59	1 (1)	6.3
	Dose volume histogram	Prostate cancer59	1 (1)	19.4
	Sexual function	Prostate cancer59	1 (1)	44.5
	Urinary function	Prostate cancer59	1 (1)	8.0
	Audiometric testing	Tympanostomy tube insertion60	1 (1)	27.3
	Impedance testing	Tympanostomy tube insertion60	1 (1)	22.7
	Multiple assessments: expiratory airflow (spirometry, bronchial challenge testing, serial peak flow testing)	Asthma61	1 (1)	51.9
	Cervical cancer (multiple components)	Cervical cancer56	1 (1)	29.7
	Colorectal cancer (multiple components)	Colorectal cancer56	1 (1)	51.6
	Skin cancer (annual dermatology examination)	Skin cancer62	1 (1)	67.3
Screening	Fecal occult blood test	Colorectal cancer (screening)63^,64	2 (2)	49.0–87.9
	Nutrition	Patients admitted to hospital65^,66	2 (3)	29.6–100.0
	Mammography^†	Breast cancer (screening)67	1 (1)	73.1
	Depression	Diabetes mellitus29	1 (1)	92.7
	Syphilis	Prenatal68	1 (1)	79.3
	Retinopathy of prematurity	Premature neonates69	1 (1)	69.6
	Pressure ulcer	Patients with spinal cord injury70	1 (1)	54.3
Blood test	Glycated hemoglobin (HbA_1c)^†	Diabetes mellitus,29^–32^,35^,47^,49 chronic kidney disease33	9 (9)	18.0–85.7
	Estimated glomerular filtration rate	Diabetes mellitus29^–32^,47	5 (5)	12.7–88.7
	Serum creatinine	Diabetes mellitus,29 chronic kidney disease33	2 (3)	14.5–73.3
	Blood culture	COPD,36 Staphylococcus aureus bacteremia71	2 (2)	12.7–95.5
	Fasting blood glucose	CVD,31 cardiac rehabilitation51	2 (4)	20.0–57.9
	C-reactive protein	Acute pancreatitis72	1 (1)	99.6
	Serum lipase	Acute pancreatitis72	1 (1)	77.4
	Multiple blood tests: lipids (various tests, e.g., total cholesterol, HDL, LDL and triglycerides)^†	Diabetes mellitus,29^,30^,32^,47^–49 CVD,31 dyslipidemia,31 cardiac rehabilitation51	8 (15)	3.2–47.0
	CBC,^† electrolytes and cardiac enzymes	COPD36	1 (1)	54.9
	Gestation diabetes blood test^‡	Gestational diabetes mellitus73	1 (1)	6.4
Imaging	Carotid imaging/Doppler^†	CVD31^,38^,39^,53^,74^–76	7 (7)	15.6–40.4
	Neuroimaging	CVD38^,40	2 (3)	1.1–10.4
	Carotid imaging/angiography	CVD40	1 (1)	32.5
	Echocardiogram	CVD31	1 (1)	52.1
	Noninvasive cardiac imaging	CVD77	1 (1)	37.5
	Radiography (chest)^†	COPD36^,50	2 (2)	3.9–35.0
	CT (head)^†	CVA31^,53	2 (2)	12.0–33.8
	CT, ultrasonography	Acute pancreatitis72	1 (1)	65.3
	CT (abdominal)^†	Acute pancreatitis72	1 (1)	43.9
	Ultrasonography (abdominal)^†	Acute pancreatitis72	1 (1)	29.8
	Breast cancer imaging (mammography, breast ultrasonography or breast MRI)	Breast cancer (in remission)56	1 (1)	35.8
	Dual-energy x-ray absorptiometry^†	Osteoporosis56	1 (1)	66.4
	CT or MRI	Prostate cancer59	1 (1)	21.0
	Bone scan^†	Prostate cancer59	1 (1)	4.5
	Transthoracic echocardiogram^†	Staphylococcus aureus bacteremia71	1 (1)	14.7
Multiple diagnostics	Diabetes care (recommended: 4 HbA_1c tests, 1 eye test and 1 cholesterol test in a 2-yr period)^§	Diabetes mellitus78	1 (1)	60.5
	Ultrasonography with or without fine needle aspiration	Thyroid incidentalomas79	1 (2)	54.0–90.0
	Thyroid-stimulating hormone with thyroid ultrasonography	Thyroid nodules80	1 (1)	47.4
	Prostate cancer assessment (Gleason score, prostate-specific antigen and T-stage)	Prostate cancer59	1 (1)	9.8
Therapeutics
Acute care procedure	Early repeat resection	Bladder cancer,81 prostate cancer41	2 (2)	51.5–72.2
	Radical prostatectomy	Prostate cancer41	1 (1)	83.0
	Fine needle aspiration	Acute pancreatitis72	1 (1)	97.3
	Endoscopy	Colorectal cancer63	1 (1)	65.3
	Mechanical bowel preparation	Colorectal surgery82	1 (1)	41.4
	Carotid endarterectomy or stenting	CVD83	1 (1)	98.1
Biophysical therapy	Enhanced recovery after surgery (ERAS bundle)	Colorectal surgery,84 breast reconstruction surgery,85 gynecologic surgeries86	3 (4)	28.0–48.8
	Nutrition: clear fluids	Colorectal surgery57	1 (1)	58.3
	Nutrition: liquid calorie supplement	Colorectal surgery57	1 (1)	98.8
	Preoperative: fasting	Colorectal surgery57	1 (1)	91.7
	Postoperative: Foley catheter	Colorectal surgery57	1 (1)	42.9
	Postoperative: mobilization	Colorectal surgery57	1 (1)	90.2
	Influenza vaccine	Diabetes mellitus,30^,32 COPD46	3 (3)	20.0–58.5
	Assisted ventilation	COPD36	1 (1)	97.7
	Pneumococcal vaccine	COPD46	1 (1)	34.0
	Chemotherapy (neoadjuvant or adjuvant)	Bladder cancer87^–89	3 (3)	64.8–81.3
	Radiation therapy^†	Prostate cancer,59 bone cancer,90 oral cancer91	3 (4)	1.4–92.6
	Nutrition: regular diet	Acute pancreatitis72	1 (1)	100.0
	Nutrition: enteral nutrition	Acute pancreatitis72	1 (1)	65.4
	Implantable cardioverter defibrillator^†	CVD92	1 (1)	27.0
	Plasma exchange^†	Not specified93	1 (1)	63.8
	Preoperative: fasting (solids)	Parenteral procedural sedation94	1 (1)	48.1
	Preoperative: fasting (liquids)	Parenteral procedural sedation94	1 (1)	5.0
	Multiple biophysical therapies: radiation therapy with androgen deprivation	Prostate cancer59	1 (1)	68.0
Psychosocial therapy	Counselling: prenatal care (weight gain, smoking, alcohol, working during pregnancy, medications in pregnancy, vitamins and minerals, exercise/active living and nutrition)	Prenatal95^–98	4 (19)	3.2–89.6
	Counselling: smoking cessation	CVD,31^,51 diabetes mellitus,30 elevated cardiometabolic risk52	4 (4)	9.2–47.2
	Counselling: exercise/active living	CVD,51 elevated cardiometabolic risk52	2 (2)	30.9–85.9
	Counselling: nutrition	Elevated cardiometabolic risk52	1 (1)	54.2
	Patient education (at least 1 type)	Patients with spinal cord injury70	1 (1)	71.0
	Counselling: preoperative	Colorectal surgery57	1 (1)	58.6
	Education postconcussion	Mild traumatic brain injury or concussion99	1 (1)	52.0
	Counselling: stress management	CVD51	1 (1)	18.7
	Counselling: self-management of heart disease	CVD51	1 (1)	9.2
Medication	Statins	CVD,51^,100^,101 diabetes mellitus,102 elevated cardiometabolic risk,52 chronic kidney disease33	6 (6)	18.5–71.0
	Multiple medications (cardiovascular)	CVD,31^,38^,40^,103^,104^¶,^,^††,^‡‡,^§§,^¶¶ diabetes mellitus,104^* hypertension104^†††	5 (9)	3.3–98.8
	ACE inhibitors or ARB	Chronic kidney disease,33 CVD,51 microalbuminuria,30 diabetes mellitus102	4 (5)	9.1–77.1
	Antihyperglycemics	Gestational diabetes mellitus,105 diabetes mellitus30^,31^,106	4 (4)	1.1–70.5
	Antiplatelet therapy	Diabetes mellitus,102 CVD51^,107	3 (4)	14.8–93.5
	Proton pump inhibitors^†	Diabetes mellitus102	1 (1)	72.3
	Thiazides	Diabetes mellitus50	1 (1)	83.0
	Smoking cessation	CVD,31 COPD46	2 (2)	52.1–76.9
	ASA	CVD31^,51	2 (4)	21.1–30.0
	Tissue plasminogen activator	CVD38^,74	2 (2)	67.6–88.1
	ACE inhibitor, ARB or β-blocker	CVD31	1 (1)	11.5
	β-Blockers	CVD51	1 (1)	30.1
	Venous thromboembolism prophylaxis^†	Cancer108^–111	4 (7)	7.3–61.3
	Antimicrobials^†	Community-acquired pneumonia,112 urinary tract infections,112 nonpurulent cellulitis,112 bacterial infections,113 COPD36	3 (5)	3.8–80.1
	Short-acting β-agonists^†	Asthma,114 COPD36	2 (2)	41.4–87.6
	Corticosteroids^†	COPD36	1 (1)	72.6
	Corticosteroids	COPD36	1 (1)	57.0
	Short-acting anticholinergics	COPD36	1 (1)	51.1
	Domperidone (antiemetic)	Colorectal surgery57	1 (1)	100.0
	Epidural	Colorectal surgery57	1 (1)	76.8
	Magnesium hydroxide	Colorectal surgery57	1 (1)	98.8
	Nonsteroidal anti-inflammatory drugs^†	Colorectal surgery57	1 (1)	65.2
	Probiotics	Colorectal surgery57	1 (1)	100.0
	Lipid lowering	Dyslipidemia31	1 (1)	8.5
	Cancer: adjuvant imatinib therapy	Gastrointestinal stromal tumours115	1 (1)	22.0
	Antihypertensives^†	Hypertension31	1 (1)	5.8
	Cancer	Lung cancer116	1 (1)	93.0
	Oral anticoagulation therapy	Not specified117	1 (1)	37.0
	Continuous midazolam infusion	Palliative sedation118	1 (1)	95.8
	Antiemetics	Pediatric oncology119	1 (1)	71.0
	Magnesium sulfate^†	Pregnancy: fetal neuroprotection120	1 (1)	23.6
	Cancer: radium-223	Prostate cancer121	1 (1)	53.5
Multiple therapeutics	Endoscopic hemostasis with high-dose IV proton pump inhibitor	Upper gastrointestinal bleeding122	1 (1)	92.9

Note: ACE = angiotensin-converting enzyme, ARB = angiotensin receptor blocker, ASA = acetylsalicylic acid, CAD = coronary artery disease, CBC = complete blood count, COPD = chronic obstructive pulmonary disease, CT = computed tomography, CVA = cerebral vascular accident (stroke), CVD = cardiovascular disease (includes the 4 main types of CVD: coronary heart disease, stroke/TIA, peripheral arterial/vascular disease and aortic disease), HDL = high-density lipoprotein, IV = intravenous, LDL = low-density lipoprotein, MRI = magnetic resonance imaging, PVD = peripheral vascular disease, TIA = transient ischemic attack.
↵* A higher number of findings is reported than the number of studies for some categories, because some studies reported more than 1 finding pertinent to that category
↵† Both underused and overused.
↵‡ Glucose challenge, oral glucose tolerance, HbA_1c or random/fasting glucose.
↵§ 60.5% of patients did not receive the recommended biannual diabetic tests. However, 15.3% received no diabetic tests, whereas 60.5% received some but not all tests.
↵¶ Angiotensin-converting enzyme inhibitors/ARBs, β-blockers or mineralocorticoid receptor antagonists.
↵** β-Blocker, lipid-lowering or other antihypertensive therapy with an ACE inhibitor, ARBs and β-blocker, an ACE inhibitor or ARB.
↵†† Acetylsalicylic acid, clopidogrel, combination of ASA and dipyramidole or warfarin.
↵‡‡ Antiplatelet or anticoagulation therapy with a lipid-lowering drug.
↵§§ Angiotensin-converting enzyme inhibitor with a lipid-lowering drug with another antihypertensive drug.
↵¶¶ Antithrombotic drug with an antihypertensive drug with a lipid-lowering drug.
↵*** Angiotensin-converting enzyme inhibitor with an ARB.
↵††† β-Blocker, with an ACE inhibitor or ARB or both, with an antihypertensive drug.