SeriesEvidence for overuse of medical services around the world
Introduction
Overuse, which Chassin and Galvin defined as ‘the provision of medical services for which the potential for harm exceeds the potential for benefit’,1 is increasingly recognised around the world. Directly measuring overuse requires a definition of appropriate care, which is often challenging. In the USA, estimates of spending on overuse vary widely: conservative estimates based on the direct measurement of individual services range from 6% to 8% of total health-care spending,2 whereas studies of geographical variation (an indirect measure) indicate that the proportion of Medicare spending on overuse is closer to 29%.3 Worldwide, overuse of individual services can be as high as 89% in certain populations.4 Although overuse has mainly been documented in high-income countries (HICs), low- and middle-income countries (LMICs) are not immune. Evidence suggests widespread overuse is occurring in countries as diverse as Australia,5 Brazil,6 Iran,7 Israel,8 and Spain.9 Overuse can coexist with unmet health-care needs, particularly in LMICs.
We aimed to highlight the significance of the problem of overuse and explore what is known regarding the scope and consequences of such, around the world. We have drawn on five systematic reviews (one unpublished)4, 10, 11, 12 of overuse to help inform this paper, supplemented with reference tracking and additional structured searches of scientific and grey literature. Subsequent papers in this Series13, 14, 15 examine the underuse of medical services worldwide, the causes of overuse and underuse, and potential solutions for both.
Section snippets
What is overuse?
“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.”
Leo Tolstoy, War and Peace
Although Chassin and Galvin's definition of overuse is succinct, and may have broad intuitive appeal, it is difficult to address. To directly measure overuse, a definition for the appropriateness of a service is required, based on evidence that considers the balance between benefits and harms for a population or individuals. However, quantifying benefits and
Measurement of overuse
Overuse can be measured in various ways. Overuse of a specific service can be measured directly within a population by use of patient registries or medical records. This approach requires a reliable definition of appropriateness for a given service, generally using an evidence-based or consensus-based guideline, or a multidisciplinary iterative panel process (eg, the RAND Appropriateness Method27) to define necessary and unnecessary use. Rates of overuse are then calculated as either the
Worldwide prevalence of overuse
Overuse is gaining increasing recognition as a worldwide problem; however, the significance of it has not yet been defined. A 2012 systematic review of the prevalence of service overuse in the USA noted that the majority of studies that directly measured overuse were focused on a relatively small number of services.4 However, indirect evidence, such as studies of geographical variation, suggests that overuse is not limited to these services in the USA.73 A more recent systematic review
Harms to patients and health-care systems
Overuse is likely to harm patients physically, psychologically, and financially, and could threaten the viability of health-care systems by increasing costs and diverting resources. However, our ability to collect strong evidence that describes the direct consequences of overuse on patients and health systems has been impeded by the same factors that challenge our ability to document overuse itself, including an incomplete evidence base for effectiveness and limited reporting of treatment harms.
Worldwide trends in overuse
Is overuse getting better or worse? This is a difficult question to answer for several reasons. First, we are only beginning to conceptualise overuse as a general system problem and to develop system-level metrics.188 Second, there are no measures in general use and providers in most countries have few incentives to report overuse. Third, health-care systems are complex and dynamic;189 reducing or eliminating overuse of one service or in one site of care could encourage overuse in another,
Conclusion
There is strong evidence for the widespread overuse of several specific medical services in many countries, suggesting that overuse is common around the world and might be increasing. However, this paper highlights a key challenge: measuring overuse and developing robust evidence for its prevalence in health services and patient populations. There is a clear need for a research agenda to develop such evidence.13 Overuse is likely to cause harm to both patients and health-care systems and thus,
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I Heath retired in January, 2010