Introducing Lown Right Care: Reducing Overuse and Underuse
Am Fam Physician. 2018 Nov 15;98(10):560.
See related Lown Right Care: Reducing Overuse and Underuse: Overuse of Cardiac Testing
In this issue, we are pleased to launch Lown Right Care: Reducing Overuse and Underuse, a collaboration between American Family Physician (AFP) and the Lown Institute.1 For decades, the Lown Institute's motto has been “Do as much as possible for the patient and as little as possible to the patient.” This new feature in AFP will promote a vision for delivering health care that is true to the evidence, balanced in its approach, and focused on the patient.
Overuse and underuse coexist in modern medicine.2 They are present in geographic regions, health systems, hospitals, and sometimes even the same patient.3–6 This linkage manifests itself as the overuse of technology and underuse of listening. However, identifying overuse and underuse is not usually straightforward because the appropriateness of care depends greatly on clinical context. The goal of this new feature is to succinctly summarize common clinical practices in which there are opportunities to move closer to the goal of “right care”— to avoid overuse by not doing unnecessary things and to improve underuse by incorporating evidence-based interventions into routine practice.
The American Board of Internal Medicine Foundation's Choosing Wisely campaign identified more than 500 clinical scenarios, based on recommendations from approximately 80 medical organizations, for which evidence shows net harm or no benefit for certain tests or interventions. These have been highlighted in previous issues of AFP.7,8 To search Choosing Wisely recommendations related to primary care, go to https://www.aafp.org/afp/recommendations/search.htm. The role of health professionals is to share their knowledge and accumulated experience about these strong and unambiguous recommendations with their patients.
Most medical decisions carry uncertainty, and evidence is often mixed. Achieving the “right care” involves matching broad general parameters established by randomized trials and other types of evidence to the unique characteristics, values, and priorities of the patient. At its core, the physician's role is to serve as a trusted guide in the face of shared uncertainty. To embrace that role, physicians must recognize that the most important dimension of patient care is the strength of our relationship with the patient. In the current time-constrained and administratively overburdened environment of primary care, there are many barriers to building this relationship—but that should not obscure our understanding of what is best for patients. In the first Lown Right Care: Reducing Overuse and Underuse feature, which appears in this issue of AFP, Dr. Roth and colleagues discuss the case of a sedentary man with an intermediate 10-year risk of a cardiovascular disease event.1 The patient is screened with electrocardiography and a cardiac stress test before starting an exercise program. After the stress test shows an abnormality, the patient undergoes cardiac catheterization that does not change his medical management. Although the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits and harms of screening with resting or exercise electrocardiography to prevent a cardiovascular disease event in asymptomatic adults at intermediate or high risk,9 this patient was clearly exposed to harms from the overuse of cardiac testing (additional medical visits, higher costs, complications from catheterization) without any corresponding benefits.
Using the Lown Right Care: Reducing Overuse and Underuse feature, we hope to spur an ongoing conversation within family medicine and the larger medical community about the kinds of changes to clinical practice that are needed to help physicians meet their professional and ethical obligations.
Editor's Note: Dr. Lin is Deputy Editor for AFP.
The Lown Right Care department project was supported with funds from the Robert Wood Johnson Foundation grant 75223.
Referencesshow all references
1. Roth AR, Lazris A, Ganatra S. Overuse of cardiac testing. Am Fam Physician. 2018;98(10):561–563....
2. Siwek J. Getting medicine right: overcoming the problem of overscreening, overdiagnosis, and overtreatment. Am Fam Physician. 2015;91(1):18–20.
3. Saini V, Brownlee S, Elshaug AG, Glasziou P, Heath I. Addressing overuse and underuse around the world. Lancet. 2017;390(10090):105–107.
4. Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. Lancet. 2017;390(10090):156–168.
5. Glasziou P, Straus S, Brownlee S, et al. Evidence for underuse of effective medical services around the world. Lancet. 2017;390(10090):169–177.
6. Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970.
7. Siwek J, Lin KW. More ways to improve health and reduce harm: Choosing Wisely phase 3. Am Fam Physician. 2014;89(5):329.
8. Middleton JL. Putting Choosing Wisely into practice. Am Fam Physician. 2018;97(7):432–433.
9. Curry SJ, Krist AH, Owens DK, et al. Screening for cardiovascular disease risk with electrocardiography: U.S. Preventive Services Task Force recommendation statement. JAMA. 2018;319(22):2308–2314.
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