Overuse and underuse of health care
Right Care Series
The Lancet, January 8, 2017
Many countries struggle with the question about sustainability, fairness, and equity of their health systems. With the focus firmly on universal health coverage as a central part to the UN Sustainable Development Goals, there is an opportunity to examine how to achieve optimum access to, and delivery of, health care and services. Underuse and overuse of medical and health services exist side-by-side with poor outcomes for health and wellbeing. This Series of four papers and accompanying comments examines the extent of overuse and underuse worldwide, highlights the drivers of inappropriate care, and provides a framework to begin to address overuse and underuse together to achieve the right care for health and wellbeing. The authors argue that achieving the right care is both an urgent task and an enormous opportunity.
The full “Right Care” series is available for free through this link, though registration is required:
Right Care 1: Evidence for overuse of medical services around the world
By Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou, Iona Heath, Somil Nagpal, Vikas Saini, Divya Srivastava, Kelsey Chalmers, Deborah Korenstein
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
• Overuse is difficult to measure and has not been well characterised
• Most studies of overuse have been done in high-income countries, but there is growing evidence that overuse is a global problem
• Overuse is likely to cause physical, psychological and financial harm to patients
• Overuse deflects resources from public health and other social spending in both low-income and high-income countries
• Overuse occurs across a wide range of medical specialties
“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.” - Leo Tolstoy, War and Peace
Right Care 2: Evidence for underuse of effective medical services around the world
By Paul Glasziou, Sharon Straus, Shannon Brownlee, Lyndal Trevena, Leonila Dans, Gordon Guyatt, Adam G Elshaug, Robert Janett, Vikas Saini
Underuse—the failure to use effective and affordable medical interventions—is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
• Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries
• Underuse is prevalent across different types of health-care systems, payment models, and health services
• The causes of underuse are multi-layered:from inadequate access, health system failures, clinicians being unaware or unskilled to provide required interventions, and patients not accessing or declining them
• Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions
• Policymakers, funders, clinicians, and civil society urgently need to recognise, invest, and resolve the slow uptake of effective, affordable, but non-promoted interventions
Right Care 3: Drivers of poor medical care
By Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug, Shannon Brownlee, John P A Ioannidis, Elliott S Fisher
The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain
The provision of care is initiated by decision making within the doctor–patient relationship, but is substantially influenced by the resources available for health care within the society, its social and political contract, the state of global and local scientific knowledge, the configuration and capacity of the delivery system, and financing mechanisms.8,22,74,214 Achievement of the right care requires an understanding of and attentiveness to all these dimensions in the development of policy choices for promotion of care that is safe, effective, sensitive to personal preferences, and just.
Although no one factor results in the provision of right care, universal health coverage should be recognised as essential at the population level. Each factor can be deemed as equally necessary but equally insufficient by itself. Reducing the role of greed by structuring financial incentives to maximise true clinical benefits and social value is key. Ensuring vigilance against error and bias, broadening research aims, and a focus on meaningful outcomes are key goals in the production of knowledge. Therefore, re-addressing imbalances of knowledge and power, not only within the clinician–patient relationship but also within delivery systems, and more broadly in society, is equally crucial. There are potentially many levers to remedy poor care, but evidence of effectiveness is very modest.
Finally, as biological creatures conscious of our susceptibilty to injury, illness, and death, deep concerns about health are universal. Public support is therefore inevitably susceptible to manipulation for private gain. Active public education, engagement, and empowerment are crucial to ensure that the forces that shape health-care delivery worldwide are truly focused on delivering the right care.
Right Care 4: Levers for addressing medical underuse and overuse: achieving high-value health care
By Adam G Elshaug, Meredith B Rosenthal, John N Lavis, Shannon Brownlee, Harald Schmidt, Somil Nagpal, Peter Littlejohns, Divya Srivastava, Sean Tunis, Vikas Sain
The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
The modern history of health care is littered with policy and practice inaction in the face of inappropriate care, often justified by an absence of evidence or uncertainty about what might result—Machiavelli’s “new order of things”. This lack of action should no longer be acceptable. Although the scale of the problem is vast and complex, a range of potentially effective remedies are available, with many more needed. Evidence-based medicine, HTA (health technology assessment), shared decision making, and countless other movements have surely nudged health systems to a point whereby we must ultimately acknowledge that a decision not to act is still a decision, and one with implications for people’s health. As efforts to improve the delivery of care continue worldwide, we must recognise that if the objective is to improve health, delivery systems need to be properly scaled and adapted to local needs and socioeconomic conditions to be maximally effective. Furthermore, delivery system leaders should remain humble about their systems’ contributions to health and should be unburdened from the task of substituting less effective medical spending for social spending. Transitions from the norm invariably cause conflict, but if efforts to achieve the right care are able to capture the full opportunity in front of us, the benefits to the wellbeing of patients, professionals, and the public as a whole are too great to condone inaction.
By Don McCanne, M.D.
Considering the amount of money we spend on health care in the United States, we should be making special efforts to see that we spend it right. This Lancet series, “Right Care,” is helpful because it defines for us where we are not providing enough care (underuse), leaving too many with unmet health care needs, and where we are providing excess care (overuse), wasting resources that could be used elsewhere, not to mention that excessive care is sometimes harmful.
Although many factors are involved in our misuse of health care, the financing system plays a significant role. We leave far too many people uninsured and underinsured which creates financial barriers to essential health care services. We have a maldistribution of our health care resources which impairs access to care in underserved areas.
By using a finance system that is based on business principles instead of public service, we are using financial disincentives, such as high deductibles, supposedly to discourage overuse but which, in fact, inappropriately incentivizes underuse. A well designed financing system, such as single payer, should go a long way toward addressing the problem of underuse, though other social factors would have to be addressed as well.
Overuse is a more difficult problem. Most health care is in a gray area. Obviously, expensive high-tech care that provides no benefit and is harmful is overuse and should be ferreted out of the system. But when high-tech care is beneficial it may be that it is no more beneficial than less expensive traditional care, but there inevitably would be disagreement on that, even after comparative effectiveness studies are completed. Many treatment regimens have potential adverse consequences, but that is often difficult to balance against the benefits that the patient may experience. Some low cost diagnostic and therapeutic interventions may lack scientific validation but if the interventions are essentially harmless and the patient is improved if for no other reason than reassurance, would this be considered overuse of our health care system? Although some might consider gray area medicine to be overuse, it would be very difficult to recover the costs of this care.
The “Right Care“ series addresses much more than the financing systems of health care, so it would be worthwhile to set time aside to read the articles (4 papers, 3 comments, and 1 perspective). It is imperative that we make “right care” a goal of reform.
But we really do need to get the financing system right. If we don’t, we’ll continue to see money wasted in more affluent areas where there is an excess capacity in high-tech care, and we’ll continue to see deficiencies in care for those who are not well served by our fragmented, dysfunctional system, market-based system.
Once we establish a publicly-financed and publicly-administered financing system, then we can work to improve the distribution and allocation of our resources to reduce waste while being sure that health care is there for people when they need it.