Tara F. Bishop

Overuse of health care services in the United States: an understudied problem.

BACKGROUND Overuse, the provision of health care services for which harms outweigh benefits, represents poor quality and contributes to high costs. A better understanding of overuse in US health care could inform efforts to reduce inappropriate care. We performed an extensive search for studies of overuse of therapeutic procedures, diagnostic tests, and medications in the United States and describe the state of the literature. METHODS We searched MEDLINE (1978-2009) for studies measuring US rates of overuse of procedures, tests, and medications, augmented by author tracking, reference tracking, and expert consultation. Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data including overuse rate, type of service, clinical area, and publication year. RESULTS We identified 172 articles measuring overuse: 53 concerned therapeutic procedures; 38, diagnostic tests; and 81, medications. Eighteen unique therapeutic procedures and 24 diagnostic services were evaluated, including 10 preventive diagnostic services. The most commonly studied services were antibiotics for upper respiratory tract infections (59 studies), coronary angiography (17 studies), carotid endarterectomy (13 studies), and coronary artery bypass grafting (10 studies). Overuse of carotid endarterectomy and antibiotics for upper respiratory tract infections declined over time. CONCLUSIONS The robust evidence about overuse in the United States is limited to a few services. Reducing inappropriate care in the US health care system likely requires a more substantial investment in overuse research.

Paid Malpractice Claims for Adverse Events in Inpatient and Outpatient Settings

CONTEXT An analysis of paid malpractice claims may provide insight into the prevalence and seriousness of adverse medical events in the outpatient setting. OBJECTIVE To report and compare the number, magnitude, and type of paid malpractice claims for events in inpatient and outpatient settings. DESIGN AND SETTING Retrospective analysis of malpractice claims paid on behalf of physicians in outpatient and inpatient settings using data from the National Practitioner Data Bank from 2005 through 2009. We evaluated trends in claims paid by setting, characteristics of paid claims, and factors associated with payment amount. MAIN OUTCOME MEASURES Number of paid claims, mean and median payment amounts, types of errors, and outcomes of errors. RESULTS In 2009, there were 10,739 malpractice claims paid on behalf of physicians. Of these paid claims, 4910 (47.6%; 95% confidence interval [CI], 46.6%-48.5%) were for events in the inpatient setting, 4448 (43.1%; 95% CI, 42.1%-44.0%) were for events in the outpatient setting, and 966 (9.4%; 95% CI, 8.8%-9.9%) involved events in both settings. The proportion of payments for events in the outpatient setting increased by a small but statistically significant amount, from 41.7% (95% CI, 40.9%-42.6%) in 2005 to 43.1% (95% CI, 42.1%-44.0%) in 2009 (P < .001 for trend across years). In the outpatient setting, the most common reason for a paid claim was diagnostic (45.9%; 95% CI, 44.4%-47.4%), whereas in the inpatient setting the most common reason was surgical (34.1%; 95% CI, 32.8%-35.4%). Major injury and death were the 2 most common outcomes in both settings. Mean payment amount for events in the inpatient setting was significantly higher than in the outpatient setting (

“Top 5” Lists Top

362,965; 95% CI,

5 Billion

348,192-

Trends in the Overuse of Ambulatory Health Care Services in the United States

377,738 vs

US Physician Practices Spend More Than

290,111; 95% CI,

15.4 Billion Annually To Report Quality Measures

278,289-

Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records

301,934; P < .001). CONCLUSION In 2009, the number of paid malpractice claims reported to the National Practitioner Data Bank for events in the outpatient setting was similar to the number in the inpatient setting.

Proton pump inhibitor use in the U.S. ambulatory setting, 2002-2009.

1. Fried TR, Tinetti ME, Towle V, O’Leary JR, Iannone L. Effects of benefits and harms on older persons’ willingness to take medication for primary cardiovascular prevention. Arch Intern Med. 2011;171(10):923-928. 2. Leipzig RM, Whitlock EP, Wolff TA, et al; US Preventive Services Task Force Geriatric Workgroup. Reconsidering the approach to prevention recommendations for older adults. Ann Intern Med. 2010;153(12):809-814. 3. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York, NY: 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. 4. Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011;83(2):278-282. 5. Nease RF Jr, Kneeland T, O’Connor GT, et al; Ischemic Heart Disease Patient Outcomes Research Team. Variation in patient utilities for outcomes of the management of chronic stable angina: implications for clinical practice guidelines. JAMA. 1995;273(15):1185-1190. 6. Man-Son-Hing M, Gage BF, Montgomery AA, et al. Preference-based antithrombotic therapy in atrial fibrillation: implications for clinical decision making. Med Decis Making. 2005;25(5):548-559. 7. Rosenfeld KE, Wenger NS, Kagawa-Singer M. End-of-life decision making: a qualitative study of elderly individuals. J Gen Intern Med. 2000;15(9):620-625. 8. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. 9. Ditto PH, Druley JA, Moore KA, Danks JH, Smucker WD. Fates worse than death: the role of valued life activities in health-state evaluations. Health Psychol. 1996;15(5):332-343.

Overuse and Systems of Care A Systematic Review

BACKGROUND Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade. METHODS Cross-sectional analysis of the 1999 and 2009 National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey, which are nationally representative annual surveys of visits to non-federally funded ambulatory care practices. We applied 22 quality indicators using a combination of current quality measures and guideline recommendations. The main outcome measures were the rates of underuse, overuse, and misuse and their 95% CIs. RESULTS We observed a statistically significant improvement in 6 of 9 underuse quality indicators. There was an improvement in the use of antithrombotic therapy for atrial fibrillation; the use of aspirin, β-blockers, and statins in coronary artery disease; the use of β-blockers in congestive heart failure; and the use of statins in diabetes mellitus. We observed an improvement in only 2 of 11 overuse quality indicators, 1 indicator became worse, and 8 did not change. There was a statistically significant decrease in the overuse of cervical cancer screening in visits for women older than 65 years and in the overuse of antibiotics in asthma exacerbations. However, there was an increase in the overuse of prostate cancer screening in men older than 74 years. Of the 2 misuse indicators, there was a decrease in the proportion of patients with a urinary tract infection who were prescribed an inappropriate antibiotic. CONCLUSIONS We found significant improvement in the delivery of underused care but more limited changes in the reduction of inappropriate care. With the high cost of health care, these results are concerning.