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Year : 2014  |  Volume : 3  |  Issue : 3  |  Page : 216-217

Quaternary prevention: Preventing over-medicalization

Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kanchipuram, Tamil Nadu, India

Date of Web Publication17-Sep-2014

Correspondence Address:
Kalaivani Annadurai
Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai Village, Thiruporur, Kanchipuram District - 603 108, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.140955

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How to cite this article:
Annadurai K, Danasekaran R, Mani G, Ramasamy J. Quaternary prevention: Preventing over-medicalization. J NTR Univ Health Sci 2014;3:216-7

How to cite this URL:
Annadurai K, Danasekaran R, Mani G, Ramasamy J. Quaternary prevention: Preventing over-medicalization. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Apr 4];3:216-7. Available from: http://www.jdrntruhs.org/text.asp?2014/3/3/216/140955


The concept of quaternary prevention was coined by Belgian Physician Marc Jamoulle. It is defined as the action taken to identify a patient or a population at risk of over-medicalization, to protect them from invasive medical interventions and provide procedures, which are scientifically and medically acceptable. [1] The emphasis of quaternary prevention is to prevent iatrogenic harms and to improve the quality of life. It is one of the major factors contributing to rising health care costs. Quaternary prevention is applied in every aspect of health care from screening, treatment to rehabilitation by avoiding over-prevention, over-diagnosis, over-prescription, and over-treatment. It includes recommendations for avoidance of screening without clinical evidence, advising vaccines without indications, inappropriate use of antibiotics, and unnecessary use of drugs such as pain killers, antidepressants, and application of incorrect rehabilitation techniques. [2]

Factors that drive overutilization include financial incentives to prescribers and dispensers by pharmaceutical companies that lead to irrational use and coverage of patients costs by a third-party (public or private insurance) payer. Another important factor in over-medicalization, especially in developed countries is defensive medicine which refers to the practice of recommending a diagnostic test or treatment that is not necessarily the best option for the patient as a means to avoid medical negligence lawsuits. Defensive medical decision making is estimated at billions of dollars annually in the Unites States (US). [3]

Reviving the concept of quaternary prevention should be given higher priority now, because of emerging antibiotic resistance, owing to irrational use of antibiotics and the rising cost of medical care, which common men cannot afford. Every year as many as 10 million US children risk side-effects from antibiotic prescriptions that are unlikely to help their upper respiratory conditions. According to a landmark report released by Centers for Disease Control and Prevention in September 2013, each year more than 2 million Americans acquire infections that are resistant to antibiotics and 23,000 die as a result. [4]

There is a growing trend of self-referral imaging whereby a nonradiologist physician refer their own patients for imaging to facilities in which they have a financial interest according to an article published in radiology. [5]

Physicians should quantify individual benefits and risks when making particular decisions. It means "first, do no harm." Physicians have a responsibility to avoid excess medical interventions with too many unnecessary or unjustified medical acts.

World Health Organization advocates 12 key interventions to promote rational use of drugs. It includes the establishment of a multidisciplinary national body to coordinate policies on medicine use, use of clinical guidelines, development and use of national essential medicines list, establishment of drug and therapeutics committees in districts and hospitals, inclusion of problem-based pharmacotherapy training in undergraduate curricula, continuing in-service medical education as a licensure requirement, supervision, audit and feedback, use of independent information on medicines, public education about medicines, avoidance of perverse financial incentives, use of appropriate and enforced regulation and sufficient government expenditure to ensure availability of medicines and staff. [6]

In an Australian study, they have advocated "traffic system" stratification for radiological test ordering. "Red" tests must be authorized by a consultant. "Amber" tests must be signed by a registrar or authorized by a consultant. "Green" tests can be ordered directly by residents or interns. In the 4 months after, the introduction of "traffic lights," each radiological method showed a reduction in both the number of tests and their associated costs. [7]

Medical professionals should deliver medical care that is scientifically acceptable, ethically justified and adjusted to the needs of the patient to achieve maximum quality with a minimum quantity of intervention.

  Acknowledgments Top

We are very grateful for our institute for their support and encouragement.

  References Top

1.Bentzen N, editor. Wonca Dictionary of General/Family Practice. Copenhagen: Maanedsskrift for Praktisk Laegegerning; 2003.  Back to cited text no. 1
2.Gérvas J. Diagnostic and therapeutic activity moderation. Quaternary and genetic prevention. Gac Sanit 2006;20 Suppl 1:127-34.  Back to cited text no. 2
3.Anderson RE. Billions for defense: The pervasive nature of defensive medicine. Arch Intern Med 1999;159:2399-402.  Back to cited text no. 3
4.Centers for Disease Control and Prevention. New guidance limits antibiotics for common infections in children. Available from: http://www.cdc.gov/media/releases/2013/p1118-get-smart.html. [Last accessed on 2013 Dec 03].  Back to cited text no. 4
5.Lungren MP, Amrhein TJ, Paxton BE, Srinivasan RC, Collins HR, Eastwood JD, et al. Physician self-referral: Frequency of negative findings at MR imaging of the knee as a marker of appropriate utilization. Radiology 2013;269:810-5.  Back to cited text no. 5
6.World Health Organization. The Pursuit of Responsible Use of Medicines: Sharing and Learning from Country Experiences. Available from: http://www.who.int/medicines/areas/rational_use/en/. [Last accessed on 2013 Dec 02].  Back to cited text no. 6
7.Phan TD, Lau KK, De Campo J. Stratification of radiological test ordering: Its usefulness in reducing unnecessary tests with consequential reduction in costs. Australas Radiol 2006;50:335-8.  Back to cited text no. 7


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