Overuse of Health Care Services: When Less Is More … More or Less

There is widespread agreement that ‘more’ is not always better in health care. Doing ‘more’ can harm patients, generate excess costs, and defy patient preferences. All are major threats to the delivery of high quality health care. Reflecting this notion, the Institute of Medicine (IOM) National Roundtable on Health Care Quality coined the term ‘overuse’ in 1998,1 adapting the definition of an ‘inappropriate’ service developed for the RAND Appropriateness Method in the 1980s.2 Overuse was defined as “a health care service [that] is provided under circumstances in which its potential for harm exceeds the possible benefit.”1 Initiatives to address overuse of medical services3 will be crucial in reducing total health care spending and iatrogenic harms.4 But recent initiatives also illustrate a potential obstacle – what is meant by overuse may be conceptually vague. In 2008, the National Priorities Partnership identified eliminating overuse as a national priority, describing it as “unscientific,” “redundant,” and “excessive” care.3 The American College of Physicians identified examples of overused screening and diagnostic tests that “clinicians often use in a manner that does not reflect high-value, cost-conscious care and does not adhere to currently available clinical guidelines.”5 The American Board of Internal Medicine Foundation’s Choosing Wisely campaign provides yet another description of overuse and helps to demonstrate the potential consequences of this ambiguity. The campaign is intended to help physicians and patients choose care that is “supported by evidence, not duplicative of other tests or procedures already received, free from harm [to patients], [and] truly necessary.”6 But the diversity of scenarios identified is substantially broader than this description. Three scenarios in Choosing Wisely differ strikingly in their underlying premise of what constitutes overuse: ‘do not repeat colorectal cancer screening for 10 years after a high-quality colonoscopy is negative in average-risk individuals,’ ‘don’t use DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors,’ and ‘don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.’6 For too frequent colorectal cancer screening, potential for harm (e.g., perforation of the colon) outweighs the benefit. Although in theory any health care intervention can cause ‘harm,’ DEXA screening for low-risk groups would not have a measureable effect on quality of life or mortality. Rather, the low likelihood of meaningful benefit is associated with the high costs of DEXA screening (estimated $70 per scan, totaling $527 million per year in the United States for women under age 657). The reasons not to initiate chronic dialysis without shared decision-making are more complex than merely avoiding the initiation of a service expected to do more harm than good. Rather, integrating individual preferences and goals into clinical decisions can help to avoid the provision of undesired care.8 Among these and other examples, no clear conceptual pattern emerges. Rather, the lists are a loose collection of services joined only by the broad notion that they should not be delivered, at least in some contexts. In our view, this lack of conceptual backbone will impede the acceptance of these initiatives by physicians. Absent a clearer conceptual framework, it will be difficult to answer key questions. For example, what types of services should next be included on a list? How should a potential area of overuse be identified a priori? How should a culture that encourages overuse or fails to discourage it be mended? A conceptual framework contemplating different dimensions of overuse might help. The framework we propose has three categories: the tradeoff between benefits and harms, the tradeoff between benefits and costs, and consideration of patient preferences. Examples of overuse can be found in each category. Making the categories explicit can help clarify the reasons to diminish a service’s use, and help those who develop and use the recommendations to make sense of seemingly disjointed issues within and across initiatives.