The Law of Diminishing Returns in Clinical Medicine: How Much Risk Reduction is Enough?

The Journal of the American Board of Family Medicine

James W. Mold¹  Laine H. McCarthy¹  Robert M. Hamm¹ 

[1]From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City

关键词: Risk Reduction;    Clinical Decision-Making;    Evidence-Based Medicine;   

DOI  :  10.3122/jabfm.2010.03.090178

学科分类：过敏症与临床免疫学

来源: The American Board of Family Medicine

【 摘 要 】

The law of diminishing returns, first described by economists to explain why, beyond a certain point, additional inputs produce smaller and smaller outputs, offers insight into many situations encountered in clinical medicine. For example, when the risk of an adverse event can be reduced in several different ways, the impact of each intervention can generally be shown mathematically to be reduced by the previous ones. The diminishing value of successive interventions is further reduced by adverse consequences (eg, drug-drug, drug-disease, and drug-nutrient interactions), as well as by the total expenditures of time, energy, and resources, which increase with each additional intervention. It is therefore important to try to prioritize interventions based on patient-centered goals and the relative impact and acceptability of the interventions. We believe that this has implications for clinical practice, research, and policy.

• Risk Reduction
• Clinical Decision-Making
• Evidence-Based Medicine

In economics, the law of diminishing returns states that, as “quantities of one variable factor are increased, while other factor inputs remain constant, all things being equal, a point is reached beyond which the addition of one more unit of the variable factor will result in a diminishing rate of return and the marginal physical product will fall.”¹ The same phenomenon applies in a variety of clinical situations, particularly in the diagnostic process and in situations where multiple tests or treatments could be recommended for the same patient. More than 15 years ago, Johnson² discussed the law of diminishing returns as it relates to the diagnostic process. The abstract of his paper begins with the following statement: “In the quest for diagnostic certainty, one can be led into a false sense of accomplishment by the results of sensitive, specific, and well-executed diagnostic tests that provide little or no diagnostic information. This is a consequence of the fact that as one approaches diagnostic certainty the useful information returned by diagnostic tests and observations approaches zero.”² The purpose of this article is to explore the clinical implications of the law of diminishing returns for risk-reduction strategies (prevention of future adverse events).

Clinical applications of the law of diminishing returns have been mentioned by several authors. Sonnenberg,³ writing about gastrointestinal interventions, wrote that the physician “has to weigh the benefit and harm of each sequential medical intervention and decide how far to extend the therapeutic chain and how much longer to proceed in fine-tuning the patient's health.” Luke and colleagues,⁴ discussing the benefits and harms associated with maternal weight gain, wrote, “These findings suggest that, beyond a certain level of weight gain, there is a point of diminishing returns (increase in birth weight) at the expense of increasing maternal postpartum obesity…” Probably the best way to illustrate the principle of diminishing returns as it applies to risk reduction is with a case.

【 授权许可】

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