• Lake Woebegon: Overuse, underuse, and misuse of health care

    The US suffers from overuse, underuse, and misuse of health care. Deborah Korenstein and colleagues expressed the problems well in a recent article in the Archives of Internal Medicine.

    There are 3 categories of quality problems in health care: underuse is the lack of provision of necessary care (eg, no aspirin prescribed after myocardial infarction), misuse is the provision of wrong care (eg, incorrect medication dosing), and overuse is the provision of medical services with no benefit or for which harms outweigh benefits.

    Their paper focuses on the overuse problem. Here’s the abstract:

    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.

    Moving on, Elizabeth McGlynn and colleagues document the underuse problem in a 2003 NEJM article.

    Background: We have little systematic information about the extent to which standard processes involved in health care — a key element of quality — are delivered in the United States.

    Methods We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores.

    Results: Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence.

    Conclusions: The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.

    With this much underuse, a suspected significant amount of overuse, and also wrong use (which I’ll leave for another post) it’s unlikely any of us have received optimal health care. And yet, how many question our doctors’ suggestions or therapies? How many think they’re not getting good care? I’ll bet most people think their care is good and appropriate. All that bad stuff is happening to other people. Welcome to Lake Woebegon.


    • I am a long-time, now semi-retired, doctor. I see these issues as very complex problems with many dimensions. I can only touch on a few.
      Firstly, as you posted just yesterday, there is not a clearcut evidence base for lots of things. One can’t be rational when there is a actual fog of limited information. The clinical trials that do pexist are often limited by conscious and unconscious biases. I am sure that you know that there is a publication bias against negative studies. Also, investigators can and do fall in love with their projects. No one ever tells you that their grandchild is reasonably average, and every presentation at national meetings is always “practice changing” and never “a small step forward.”
      Secondly, since medical practioners are limited and working more and more in industrial models of production, there is a need to get things done in a time efficient rather than a cost efficient manner. The costs of medicine are bourne by third parties, but the time costs come out of the doctor’s life. That results in quick prescriptions being given out for problems. I think most docs know that the evidence for SSRI’s is not strong, but the alternative of counseling, etc, is a time eater.
      Thirdly, patients have their own ideas and demands. Yes, people want antibiotics for colds, MRI’s for usual backaches, PSA testing, and lots of other things.
      These are not the only problems, just some that occured to me this morning.