AIM: Overuse of healthcare services must be addressed

Often healthcare services in the U.S. are overutilized, which can lead to high healthcare spending. Expanding guidelines and establishing appropriate use criteria for more healthcare services could help eliminate this overuse and in turn reduce high healthcare spending, according to an editorial published in the Jan. 24 issue of the Archives of Internal Medicine.

Three groups of quality problems exist in healthcare:

• Underuse is the lack of provision of necessary care (e.g., no aspirin used post-MI);
• Misuse is the provision of wrong care (e.g., incorrect medication dosing); and
• Overuse is the provision of medical services with no benefit or for which harm outweighs the benefit.

Improper use or overuse leads to the high costs seen today in the healthcare industry. In fact, it has been estimated that nearly 30 percent of U.S. health spending may be due to overuse, according to Deborah Korenstein, MD, of the Mount Sinai School of Medicine in New York City, and colleagues.

“Despite broad acknowledgment that overuse is common and costly, overuse research has been underemphasized compared with research on underuse of health services, which may limit our understanding,” Korenstein and colleagues noted. But because appropriate care is hard to define, overuse has been left out of quality of care assessments.

To better understand the trends in overuse of healthcare services across the U.S., Korenstein and colleagues performed a systemic review of multiple published works to help determine the rate of overuse of therapeutic procedures, diagnostic testing and medication use in the U.S.

To do so, Korenstein et al identified 172 studies in the final review. Fifty-three related to therapeutic procedures, 38 related to diagnostic testing and 81 related to medication use. Of the studies, antibiotics for upper respiratory tract infections were most commonly studied (59 articles), followed by noninterventional coronary angiography (16 articles), coronary endartarectomy (CEA, 13 articles) and CABG (10 articles). Coronary angiography, CEA and CABG were the focus of 68.7 percent of all studies of therapeutic procedures.

The researchers reported that CABG overuse was low, usually lower than 15 percent. Rates of coronary angiography overuse were also low—20 percent or less. The rates of inappropriate CEA ranged from 1 percent to 33 percent before 2000 and were less than 11 percent in all studies after 2000.

“Reductions in inappropriate use of health services over time may be related to publication of guidelines for their appropriate use, as in the case of CEA, specific interventions to reduce overuse, or national educational campaigns as for antibiotics,” the authors wrote.

The researchers said that high quality guidelines and targeted interventions could help to reduce overuse; however, they added that the “persistence of overuse of some services demonstrates that reducing inappropriate care can be challenging.”

Because guidelines differ on challenging interventions, like CEA, many instances of care cannot be defined as appropriate or inappropriate.

“More investigation into the appropriateness of preventive services would allow for alignment of diverse guidelines and the incorporation of overuse indicators into standard quality measures,” the authors summed. “Expanding the evidence base and establishing appropriateness criteria for a broader range of services could help target and eliminate overuse in healthcare services, which could reduce healthcare spending without adversely affecting the health of the public.”