Underuse, overuse, right use

Mitchell Katz, Deborah Grady, and Rita Redberg in the JAMA Internal Medicine:

Kale and colleagues developed a set of quality indicators of underuse, overuse, and misuse of medical treatment. Underuse was failure to provide an evidence-based treatment (eg, a beta-blocker in a person with coronary artery disease). Overuse was performing an intervention that is not recommended (eg, prescribing antibiotics for upper respiratory infections). Misuse was giving the wrong treatment (eg, prescribing a medication that is dangerous for elderly persons to someone 65 years or older).

Using 2 national databases, the authors performed cross-sectional comparisons of outpatient visits in 1999 to visits in 2009. In the absence of bias toward overtreatment, we would expect equal progress to be made on all 3 types of indicators. The true pattern was much more interesting. Six of the 9 underuse indicators improved; 1 of 2 of the misuse indicators improved; but only 2 of the 11 overuse indicators improved and 1 got significantly worse (prostate screening became more common among men older than 74 years).

Given incentives, this is what one would expect. We need as much or more pressure to move overuse toward “right use” (for lack of a better term) as we do to reduce underuse. What we want to avoid is turning underusers into overusers. But that may be what we do, at least for some time.

Kale, et al.’s paper is here.


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