Elsevier

The Lancet

Volume 390, Issue 10090, 8–14 July 2017, Pages 156-168
The Lancet

Series
Evidence for overuse of medical services around the world

https://doi.org/10.1016/S0140-6736(16)32585-5Get rights and content

Summary

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.

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,

References (201)

  • A Kotwani et al.

    Antibiotic-prescribing practices of primary care prescribers for acute diarrhea in New Delhi, India

    Value Health

    (2012)
  • L Elli et al.

    Defensive medicine practices among gastroenterologists in Lombardy: between lawsuits and the economic crisis

    Dig Liver Dis

    (2013)
  • JD Sammon et al.

    Patterns of declining use and the adverse effect of primary androgen deprivation on all-cause mortality in elderly men with prostate cancer

    Eur Urol

    (2015)
  • SA Yap et al.

    Do we continue to unnecessarily perform ipsilateral adrenalectomy at the time of radical nephrectomy? A population based study

    J Urol

    (2012)
  • MR Chassin et al.

    The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality

    JAMA

    (1998)
  • DM Berwick et al.

    Eliminating waste in US health care

    JAMA

    (2012)
  • JE Wennberg et al.

    Geography and the debate over Medicare reform

    Health Aff (Millwood)

    (2002)
  • D Korenstein et al.

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

    Arch Intern Med

    (2012)
  • AG Elshaug et al.

    Over 150 potentially low-value health care practices: an Australian study

    Med J Aust

    (2012)
  • AJ Barros et al.

    Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off

    Rev Saude Publica

    (2011)
  • F Bahadori et al.

    The trend of caesarean delivery in the Islamic Republic of Iran

    East Mediterr Health J

    (2014)
  • A Goldberg et al.

    Appropriateness of diagnosis of unstable angina pectoris in patients referred for coronary arteriography

    Expl Clin Cardiol

    (2008)
  • W Mao et al.

    Systematic review on irrational use of medicines in China and Vietnam

    PLoS One

    (2015)
  • P Glasziou et al.

    Evidence for underuse of effective medical services around the world

    Lancet

    (2017)
  • V Saini et al.

    Drivers of poor medical care

    Lancet

    (2017)
  • AG Elshaug et al.

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

    Lancet

    (2017)
  • DJ Morgan et al.

    Setting a research agenda for medical overuse

    BMJ

    (2015)
  • R Lopert

    Evidence-based decision-making within Australia's pharmaceutical benefits scheme

    Issue Brief (Commonw Fund)

    (2009)
  • SD Shillcutt et al.

    Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules

    Pharmacoeconomics

    (2009)
  • MR Gold et al.

    Medicare and cost-effectiveness analysis: time to ask the taxpayers

    Health Aff (Millwood)

    (2007)
  • B Sirovich et al.

    Discretionary decision making by primary care physicians and the cost of U.S. Health care

    Health Aff (Millwood)

    (2008)
  • A Chandra et al.

    Technology growth and expenditure growth in health care

    J Econ Lit

    (2012)
  • X Huang et al.

    Overuse of cardiovascular services: evidence, causes, and opportunities for reform

    Circulation

    (2015)
  • T Blank et al.

    Understanding treatment decision making: contexts, commonalities, complexities, and challenges

    Ann Behav Med

    (2006)
  • P Shekelle

    The appropriateness method

    Med Decis Making

    (2004)
  • MR Partin et al.

    Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration

    J Gen Intern Med

    (2012)
  • BE Sirovich et al.

    Too Little? Too Much? Primary care physicians' views on US health care: a brief report

    Arch InternMed

    (2011)
  • DV Makarov et al.

    Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the Choosing Wisely Campaign

    JAMA Oncol

    (2015)
  • DJ Handelsman

    Pharmacoepidemiology of testosterone prescribing in Australia, 1992–2010

    Med J Aust

    (2012)
  • R Cobos et al.

    Variability of indication criteria in knee and hip replacement: an observational study

    BMC Musculoskelet Disord

    (2010)
  • DL Riddle et al.

    Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study

    Arthritis Rheumatol

    (2014)
  • Geographic variations in health care: what do we know and what can be done to improve health system performance?

    (2014)
  • The NHS Atlas of Variation in Healthcare: reducing unwarranted variation to increase value and improve quality

  • Fisher ES, Bell JE, Tomek IM, Esty AR, Goodman DC. Trends and regional variation in hip, knee and shoulder replacement....
  • C Carpeggiani et al.

    Inappropriateness of cardiovascular radiological imaging testing: a tertiary care referral center study

    PLoS One

    (2013)
  • PS Chan et al.

    Appropriateness of percutaneous coronary intervention

    JAMA

    (2011)
  • S Brownlee et al.

    Elective Heart Procedures in California: a close-up of geographic variation

    (2014)
  • M Iyer

    44% advised unnecessary surgery: 2nd opinion-givers

    The Times of India

    (Jan 4, 2015)
  • YM Chao et al.

    Appropriateness of hysterectomy in Taiwan

    J Formos Med Assoc

    (2005)
  • J Schilling et al.

    Evaluation of Swiss guidelines for the indication for hysterectomy in relation to patient outcome

    Gynakol Geburtshilfliche Rundsch

    (2009)
  • Cited by (617)

    • Patient blood management

      2023, Best Practice and Research: Clinical Anaesthesiology
    View all citing articles on Scopus

    I Heath retired in January, 2010

    View full text