Evidence for overuse of medical services around the world

Abstract

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.

Conflict of interest statement

Declaration of Interests

AGE receives salary support as the HCF Research Foundation Principal Research Fellow, and holds research grants from The Commonwealth Fund and Australia’s National Health and Medical Research Council (ID 1109626 and 1104136). AGE receives consulting/sitting fees from Cancer Australia, the Capital Markets Cooperative Research Centre-Health Quality Program, NPS MedicineWise (facilitator of Choosing Wisely Australia), The Royal Australasian College of Physicians (facilitator of the EVOLVE program) and the Australian Commission on Safety and Quality in Health Care. JD reports grants from NHMRC. VS and SB receive support from a grant from the Robert Wood Johnson Foundation. DK was supported by a Cancer Center Support Grant from the National Cancer Institute to Memorial Sloan Kettering Cancer Center (award number P30 CA008748). KC, KChalmers, SN, DS, PG, and IH report nothing to disclose.

Copyright © 2017 Elsevier Ltd. All rights reserved.

Figures

Figure 1. Grey Zone Services

Some medical tests and treatments are of clear benefit, and some are clearly ineffective and therefore offer only net harm. There is clear underuse of effective services, and clear overuse of ineffective services. Many services fall into a more nebulous grey zone, where evidence is lacking, or the services is delivered to inappropriate patients, or to patients who are poorly informed.

Figure 2. Overuse of Selected Services in Four Countries

Figure 2 explanatory note: Estimates from the literature of the proportion of patients that received various low-value services, out of the relevant patient population. The populations are based in four locations (US: circle/green, Canada: triangle/orange, Australia: diamond/purple, Sweden: upside-down triangle/pink). Abbreviations: Patients (pts); with (w); cancer (cn); imaging (img); preoperative (preop); total knee arthroplasty (TKA); lower back pain (LBP); computed tomography (CT); benign prostate hyperplasia (BPH); primary androgen deprivation therapy (pADT); bone scintigraphy (BS); positron emission tomography (PET); tumour marking studies (TMS); dual-energy x-ray absorptiometry (DXA); echocardiography (ECG); pulmonary function test (PFT); ipsilateral adrenalectomy (IA); radioactive iodine treatment (RAI); carotid artery disease (CAD); congestive heart failure (CHF); magnetic resonance imaging (MRI). Figure adapted and updated from Chalmers and Elshaug.