Overuse is systemic

A new paper by Keyhani et al. titled “Overuse and Systems of Care: A Systematic Review” caught my eye. I’m a sucker for systematic reviews, particularly one on overuse as it relates to systems of care. This is TIE candy.

Background: Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.

Objective: To compare rates of overuse in different health care systems and examine whether certain systems of care or insurers have lower rates of overuse of health care services.

Data Sources: Articles published in MEDLINE between 1978, the year of publication of the first framework to measure quality, and June 21, 2012.

Study Selection: Included studies compared rates of overuse of procedures, diagnostic tests, or medications in at least 2 systems of care.

Data Extraction: Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data.

Results: We identified 7 studies which [*] compared rates of overuse of 5 services across multiple different health care settings. National rates of inappropriate coronary angiography were similar in Medicare HMOs and Medicare FFS (13% vs. 13%, P=0.33) and in a state-based study comparing 15 hospitals in New York and 4 hospitals in a Massachusetts-managed care plan (4% vs. 6%, P>0.1). Rates of carotid endarterectomy in New York State were similar in Medicare HMOs and Medicare FFS plans (8.4% vs. 8.6%, P=0.55) but nonrecommended use of antibiotics for the treatment of upper respiratory infection was higher in a managed care organization than a FFS private plan (31% vs. 21%, P=0.02). Rates of inappropriate myocardial perfusion imaging were similar in VA and private settings (22% vs. 16.6%, P=0.24), but rates of inappropriate surveillance endoscopy in the management of gastric ulcers were higher in the VA compared with private settings (37.4% vs. 20.4%–23.3%, P<0.0001).

Conclusions: The available evidence is limited but there is no consistent evidence that any 1 system of care has been more effective at minimizing the overuse of health care services. More research is necessary to inform current health care reform efforts directed at reducing overuse. [Emphasis added.]

Over nearly 35 years there were only seven studies comparing overuse across systems of care. Actually, all of them were published since 1995 and all but three since 2006. Still, is this enough evidence to go on, especially considering the studies focused on specific types of overuse, not overuse writ large? I’m underwhelmed.

That grain (or shaker) of salt aside, the results are plausible enough. (Enter speculation mode.) The US health system seems to be, in general, roughly equally inefficient no matter where you look. I buy that. It’d be a stretch to make policy recommendations based on such a thin bed of evidence, but one might be that pushing the system a bit more toward managed care or a bit more toward integrated delivery systems isn’t likely to cause major efficiency gains.

Something more fundamental is likely needed, something that embeds more deeply into the culture of provision of care or the culture of patients. Somehow, “we” need to care a lot more about cost, quality — value — than we do. We need to stop mistaking more for better. Of course, not paying for more is a start, but that alone seems insufficient, not to mention hard to do properly.

The US medical culture, either from a practitioner or patient view, will be hard to change. Beyond the myriad ideas both in law and suggested, I don’t know how to do it. I don’t know which ideas will do any good. Maybe many of them will help. Maybe none of them. My best bet at the moment is that, coupled with better alignment of incentives on both sides of the medical transaction (patient and provider), the continued drum beat of evidence pointing to the large amounts of low value care, and even to specific instances of low value care, will eventually penetrate. That’s my hope, anyway.

* This use of “which” is incorrect. It should be “that.” This really irritates me.


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