Overuse, Misuse of Certain Ambulatory Medical Services Increasing

Although advances in the delivery of underused care were significant during the decade between 1999 and 2009, targeting and reducing inappropriate care did not see the same gains, according to a recent study (abstract) in JAMA Internal Medicine -- formerly the Archives of Internal Medicine -- leading the study's authors to conclude that reducing inappropriate care has not been a real focus of the quality-of-care movement.

The study "Trends in the Overuse of Ambulatory Health Care Services in the United States" sought to determine whether respective levels of underuse, overuse and misuse of health care services in the ambulatory setting have improved during the past decade. According to the study's authors, although significant advances have been recorded in the delivery of underused care between 1999 and 2009, only limited reductions in inappropriate care (i.e., overuse and misuse of the specific services examined) were realized during that period. With the high cost of health care that's currently facing the United States, these results are concerning, the authors said.

"Reducing health care costs and improving the quality of care in the United States can be achieved by reducing overuse and misuse of health care services, but it will require making uncomfortable decisions that patients, physicians and policymakers have been historically unwilling to make," the authors wrote. "Developing clinical practice guidelines that define when care should not be delivered and performance measures to address inappropriate care are critical steps to advance the mission of increasing the value and efficiency of health care delivery."

As defined by the authors:

According to the study, improvement was found in six out of nine measures of underuse versus only three of 13 measures of inappropriate care.

"In an analysis of the estimated $700 billion that is wasted annually in our health care system, overuse … has been identified as a significant component, equaling roughly $280 billion," the authors wrote. "Our findings of the continued delivery of inappropriate care, such as the use of prostate-specific antigen (PSA) testing in older men and cervical cancer screening in older women, are consistent with other studies that demonstrate the persistence of inappropriate care."

The authors said that although several possible reasons exist to explain their findings, one of the most likely is that targeting and reducing inappropriate care has not been a significant focus in the quality-of-care movement. Instead, they wrote, clinical practice guidelines have "mostly taken the form of underuse measures."

"In light of the abundance of literature and practice guidelines related to underuse, our finding that the overuse of ambulatory care may have changed little during the past 10 years is not entirely unexpected," the authors wrote. "Reducing inappropriate care will require the same attention to guideline development and performance measurement that was directed at reducing the underuse of needed therapies."

Unfortunately, developing guidelines to reduce inappropriate care is not an easy process because overuse can be difficult to identify in publicly reported databases or hospital claims data, and determining whether patients received inappropriate procedures is an extremely detailed, time-consuming process. More importantly, the authors noted, no formal effort to develop and promote the use of standardized measures to combat overuse exists.

"There is good evidence that screening for prostate cancer in the very elderly and infirm is not beneficial, and yet it continues to be performed at alarming rates," the authors wrote. "Despite being easily measured, this practice has not been evaluated as a potential performance measure or adopted by the Healthcare Effectiveness Data and Information Set."

The authors also point to political and cultural challenges that stand in the way of developing overuse guidelines, citing the attacks on the Agency for Healthcare Research and Quality after it recommended against the use of surgery in the initial management of low-back pain in 2003, as well as the flack thrown at the U.S. Preventive Services Task Force in the wake of its 2012 recommendation against PSA screening in asymptomatic men.

On a positive note, the authors pointed to the AAFP-supported Choosing Wisely campaign as an example of collaboration between disparate physician groups that share a goal of promoting high-quality, cost-effective care.

"These initiatives may be foreshadowing a change in practice culture that may be necessary to begin the hard work of addressing the delivery of inappropriate care in the U.S. health care system," the authors wrote.