Systematic Overuse of Healthcare Services: A Conceptual Model

A perfect storm of factors influences the overuse of healthcare services in the USA. Considerable attention has been placed on geographic variation in utilization; however, empiric data has shown that geographic variation in utilization is not associated with overuse. While there has been renewed interest in overuse in recent years, much of the focus has been on the overuse of individual procedures. In this paper we argue that overuse should be thought of as a widespread and pervasive phenomenon that we coin as systematic overuse. While not directly observable (i.e., a latent phenomenon), we suggest that systematic overuse could be identified by tracking a portfolio of overused procedures. Such a portfolio would reflect systematic overuse if it is associated with higher healthcare costs and no health benefit (including worse health outcomes) across a healthcare system. In this report we define and conceptualize systematic overuse and illustrate how it can be identified and validated via a simple empirical example using several Choosing Wisely indicators. The concept of systematic overuse requires further development and empirical verification, and this paper provides an important first step, a conceptual framework, to that end.

[1]  D. Buckman,et al.  Are Physicians’ Recommendations For Colorectal Cancer Screening Guideline-Consistent? , 2011, Journal of General Internal Medicine.

[2]  Salomeh Keyhani,et al.  Overuse and Systems of Care: A Systematic Review , 2013, Medical care.

[3]  Hsien-Yen Chang,et al.  The State of Overuse Measurement , 2013, Medical care research and review : MCRR.

[4]  R. Gonzales,et al.  The Context of Antibiotic Overuse , 2012, Annals of Internal Medicine.

[5]  Gerard F Anderson,et al.  U.S. health care spending in an international context. , 2004, Health affairs.

[6]  A. Chawla,et al.  Explaining drug spending trends: does perception match reality? , 2000, Health affairs.

[7]  Salomeh Keyhani,et al.  The underuse of overuse research. , 2008, Health services research.

[8]  C. Cassel,et al.  Choosing wisely: helping physicians and patients make smart decisions about their care. , 2012, JAMA.

[9]  Stacey L. Sheridan,et al.  Low Health Literacy and Health Outcomes: An Updated Systematic Review , 2011, Annals of Internal Medicine.

[10]  Deborah Grady,et al.  Less is more: how less health care can result in better health. , 2010, Archives of internal medicine.

[11]  R. Brook.  The role of physicians in controlling medical care costs and reducing waste. , 2011, JAMA.

[12]  R. Falk,et al.  The Relationship Between Geographic Variations and Overuse of Healthcare Services: A Systematic Review , 2012, Medical care.

[13]  David Wennberg,et al.  The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care , 2003, Annals of Internal Medicine.

[14]  Zackary Berger,et al.  The "top 5" lists in primary care: meeting the responsibility of professionalism. , 2011, Archives of internal medicine.

[15]  A. Gittelsohn,et al.  Small Area Variations in Health Care Delivery , 1973, Science.

[16]  James S Goodwin,et al.  Overuse of screening colonoscopy in the Medicare population. , 2011, Archives of internal medicine.

[17]  V. Fuchs.  Eliminating "waste" in health care. , 2009, JAMA.

[18]  J. Lavis,et al.  Appropriateness in health care delivery: definitions, measurement and policy implications. , 1996, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[19]  N. Petry,et al.  Psychiatric disorders are associated with hospital care utilization in persons with hypertension , 2008, Social Psychiatry and Psychiatric Epidemiology.

[20]  M. Cabana,et al.  Why don't physicians follow clinical practice guidelines? A framework for improvement. , 1999, JAMA.

[21]  Kitty S. Chan,et al.  Identifying Possible Indicators of Systematic Overuse of Health Care Procedures With Claims Data , 2014, Medical care.

[22]  S. Kaplan,et al.  Patients' role in the use of radiology testing for common office practice complaints. , 2001, Archives of internal medicine.

[23]  A. Sood,et al.  Non-evidence-based variables affecting physicians' test-ordering tendencies: a systematic review. , 2007, The Netherlands journal of medicine.

[24]  J. Bridges,et al.  Team Structure and Adverse Events in Home Health Care , 2007, Medical care.

[25]  R. Jiménez-García,et al.  Inappropriate Overuse of Inhaled Corticosteroids for COPD Patients: Impact on Health Costs and Health Status , 2011, Lung.

[26]  Sharon-Lise T Normand,et al.  Use of drug-eluting stents as a function of predicted benefit: clinical and economic implications of current practice. , 2012, Archives of internal medicine.

[27]  Y. Zhang,et al.  Ambulatory antibiotic use and prescription drug coverage in older adults. , 2010, Archives of internal medicine.

[28]  Elizabeth Docteur,et al.  Doing Better by Doing Less: Approaches to Tackle Overuse of Services , 2013 .

[29]  B. Obama.  Modern health care for all Americans. , 2008, The New England journal of medicine.

[30]  D. Berwick,et al.  The triple aim: care, health, and cost. , 2008, Health affairs.

[31]  D. Ransohoff,et al.  Adverse Events After Outpatient Colonoscopy in the Medicare Population , 2009, Annals of Internal Medicine.

[32]  Saudi Arabia,et al.  in the United States and in , 1981 .

[33]  Devin R. Nickol,et al.  How Do Community Practitioners Decide Whether to Prescribe Antibiotics for Acute Respiratory Tract Infections? , 2008, Journal of General Internal Medicine.

[34]  Paul M Ness,et al.  Variability in Blood and Blood Component Utilization as Assessed by an Anesthesia Information Management System , 2012, Anesthesiology.

[35]  M. Chassin,et al.  The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. , 1998, JAMA.

[36]  M. Grossman,et al.  A wolf dressed in sheep’s clothing , 2005, Applied health economics and health policy.

[37]  B. McNeil,et al.  Impact of Underuse, Overuse, and Discretionary Use on Geographic Variation in the Use of Coronary Angiography After Acute Myocardial Infarction , 2001, Medical care.

[38]  D. Berwick,et al.  Eliminating waste in US health care. , 2012, JAMA.

[39]  Victor R Fuchs,et al.  The perfect storm of overutilization. , 2008, JAMA.

[40]  S. Lipsitz,et al.  Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer. , 2011, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[41]  Peter R. Orszag,et al.  Addressing rising health care costs--a view from the Congressional Budget Office. , 2007, The New England journal of medicine.

[42]  D. McClish,et al.  Somatic symptom burden in adults with sickle cell disease predicts pain, depression, anxiety, health care utilization, and quality of life: the PiSCES project. , 2011, Psychosomatics.

[43]  B Starfield,et al.  Is US health really the best in the world? , 2000, JAMA.

[44]  Jordi Rello,et al.  Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?: a survey based on the opinions of an international panel of intensivists. , 2002, Chest.

[45]  R H Brook,et al.  Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. , 1987, JAMA.

[46]  P. Shekelle,et al.  Efficiency and its measurement: what practitioners need to know. , 2009, The American journal of managed care.

[47]  Mark Chun,et al.  IT in Healthcare , 2010 .

[48]  E. Fisher,et al.  Malpractice liability costs and the practice of medicine in the Medicare program. , 2007, Health affairs.

[49]  R H Brook,et al.  Does inappropriate use explain small-area variations in the use of health care services? , 1990, JAMA.

[50]  Elliott S Fisher,et al.  Health Care Quality, Geographic Variations, and the Challenge of Supply-Sensitive Care , 2003, Perspectives in biology and medicine.

[51]  J. Rabinowitz,et al.  Elective amniocentesis in low-risk pregnancies: decision making in the era of information and uncertainty. , 2001, American journal of public health.

[52]  J. Tabrizi.  Improving Health Care Quality , 2010 .

[53]  R. Hays,et al.  Racial and ethnic differences in patients' preferences for initial care by specialists. , 2004, The American journal of medicine.

[54]  Carla M Bann,et al.  The public's response to the U.S. Preventive Services Task Force's 2009 recommendations on mammography screening. , 2011, American journal of preventive medicine.

[55]  Salomeh Keyhani,et al.  Overuse of health care services in the United States: an understudied problem. , 2012, Archives of internal medicine.

[56]  J. Iglehart.  The political fight over comparative effectiveness research. , 2010, Health affairs.

[57]  S. Lipsitz,et al.  Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States , 2012, Cancer.

[58]  D. Lorenzetti,et al.  Appropriateness of healthcare interventions: Concepts and scoping of the published literature , 2008, International Journal of Technology Assessment in Health Care.