Shannon Brownlee

Evidence for overuse of medical services around the world

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.

Setting a research agenda for medical overuse

Although overuse in medicine is gaining increased attention, many questions remain unanswered. Dan Morgan and colleagues propose an agenda for coordinated research to improve our understanding of the problem

Levers for addressing medical underuse and overuse: achieving high-value health care

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.

Drivers of poor medical care

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.

Evidence for underuse of effective medical services around the world

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.

Addressing overuse and underuse around the world

www.thelancet.com Vol 390 July 8, 2017 105 The benefits of modern medical care have advanced the health of populations around the world, but with better health has come rising health-care spending. Not surprisingly, there is global interest in optimising the delivery of health services, exemplified by the universal health coverage (UHC) and waste in research campaigns. Comparatively neglected is a central paradox that afflicts high-income countries (HICs) and low-income and middle-income countries (LMICs) alike: the failure to deliver needed services alongside the continuing delivery of unnecessary services. The Lancet Series on right care aims to bring these two issues— overuse and underuse—to the centre of global health strategies (panel). Inappropriate care is a widespread phenomenon. Doctors in HICs and LMICs continue to underuse simple and inexpensive interventions, and to overuse ineffective but familiar, lucrative, or otherwise convenient services, despite potential patient harms. Underuse and overuse occur whether providers are paid fee-for-service or salaried in market-driven and highly regulated systems, or in systems that are funded publicly and privately. Moreover, these two issues can affect the same country, the same health organisation, the same hospital, and even the same patient. Getting better value from health care—ie, more health per dollar spent—is a challenge common to all nations. Underuse leaves populations and patients in any setting vulnerable to avoidable disease and suffering. Overuse causes avoidable physical harms from the irreducible rate of adverse events, and financial harms from wasted resources which could be better spent on services that promote health. In most HICs, rising health-care costs with little or no marginal improvement in population-based outcomes have become a concern across the political spectrum, and the scope of the waste is staggering. In 2010, the US Institute of Medicine estimated the annual excess cost from health-care waste in the USA at US

Why the FDA can't protect the public

765 billion— with at least

An untold story

210 billion in unnecessary services and

Naming names: is there an (unbiased) doctor in the house?

55 billion in missed disease prevention. In LMICs, the development of insurance schemes coupled with the transfer of seemingly advanced, but often merely wasteful, norms of medical care through globalised markets means that scarce resources are triple-taxed by the continuing burden of poverty, malnutrition, and infectious disease, rapidly rising rates of chronic diseases, and the adoption of expensive yet unproven medical technologies. Defining the right care and understanding the forces that work against it constitute a crucial pathway to real affordability. Failing to do so will leave universal access to high-quality, cost-effective, and compassionate care an ever-receding mirage. The Right Care Series creates a framework for understanding overuse, and underuse around the world, the common drivers of poor care, and the potentially scalable remedies to each. What is the right care? Answering this question remains a challenge, largely because most medical services fall into a grey zone where the probability of benefit or harm is uncertain for any individual. This zone of uncertainty has at least four dimensions: (1) services for which high-quality evidence of clinical effectiveness is lacking; (2) patients for whom there is irreducible uncertainty about the potential for benefit and harm; (3) patient preferences, whether for quantity or quality of life, avoidance of harm, or ability/willingness to incur financial costs; and (4) varying cost utilities of national political economies. Globally, definitions of overuse and underuse are necessarily context dependent; the same clinical service may have different utility when refracted through the lens of the national delivery system or wealth of a country. This last dimension includes both a nation’s capacity to pay for health care and its political willingness to do so. Underuse is generally driven in LMICs by insufficient medical resources and patients’ inability to pay. In HICs, underuse often reflects a maldistribution of resources driven by inequalities of economic or cultural power, and profit seeking for high-margin technologies at the expense of less expensive treatments. Just as inadequate capacity drives underuse, excess capacity drives overuse—so-called supply-sensitive demand. With inadequate or insufficiently independent regulatory mechanisms, particularly in the absence of adequate methods for determining population needs, many HICs have overinvested in hospital-based infrastructure and workforce while underinvesting in community-based services such as primary care or home care. A few countries, such as Denmark and China, are attempting Addressing overuse and underuse around the world

Overtreatment in the United States

Medical device makers often fail to properly conduct safety studies and the US Food and Drug Administration provides scant oversight. Jeanne Lenzer and Shannon Brownlee look at some of the problems with post approval surveillance of novel devices