Overuse Accounts for Up to 30% of Healthcare Spending

January 26, 2012

January 26, 2012 — Overuse of therapeutic procedures, diagnostic tests, and medications is an understudied problem that may account for as much as 30% of healthcare spending in the United States and result in harm to patients, according to a review published in the January 23 issue of the Archives of Internal Medicine.

The review included 172 scientific articles documenting 241 studies of overuse published between 1978, the year in which the first "landmark" article on quality measurement was published, and 2009. Overuse was defined as interventions in which negative consequences, including unnecessary costs, outweighed the benefits of care.

The analysis revealed "that inappropriate use of investigated services is often a problem and that rates of overuse vary widely," write Deborah Korenstein, MD, from the Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York City, and colleagues.

The 4 most common health services examined in the studies included in the review were antibiotics for upper respiratory infections, coronary angiography, carotid endarterectomy, and coronary artery bypass grafting and revascularization.

The antibiotic overuse ranged between 2.0% and 89.0% during the 21-year span of the review. For coronary angiography, the rates of overuse ranged between 4.0% and 21.8%.

Overuse of carotid endarterectomy ranged between 1.0% and 33.0%; for coronary artery bypass grafting and revascularization, it was from 1.4% to 15.0%.

These were the interventions most widely studied during the years for which the researchers collected articles, but there were others healthcare services that appeared to be more overused. Those included follow-up screening colonoscopies, with up to a 60.8% rate of overuse; the prescription of bronchodilators, at up to 81.0% overuse; and hysterectomy, at up to 70.0% overuse.

Some areas of overuse, such as the use of antibiotics for upper respiratory infections and carotid endarterectomy, appeared to decline over time. Others, such as upper endoscopy, appeared to increase.

"Despite broad acknowledgment that overuse is common and costly, overuse research has been underemphasized compared with research on underuse of health services," the authors write.

The current study was undertaken "[t]o help define the scope of health care overuse, document trends in overuse over time, and inform discussions about reducing overuse," they write.

There were limitations to the study. The lack of Medical Subject Heading terminology for overuse, note the authors, might have resulted in omissions. It also was not possible to have 2 reviewers examine each article, which might have led to errors. The authors included a number of studies using the same patient sample to explore overuse in different populations, so the sample may overrepresent the data on some clinical services. Finally, the review does not include articles published after 2009.

The study looked at only some of the many healthcare services that might be overused. High-quality national guidelines to measure overuse need to be developed to facilitate studies on more healthcare services in the future.

"What is most striking about this report is how hard the authors searched for data on overuse of health care and how little they found," writes Mitchell H. Katz, MD, director of the Los Angeles County Department of Health Services in California, in an accompanying Editor's Note. To improve healthcare in the United States, Dr. Katz writes, we must know as much about overuse of health care as we do about its underuse. "This article," he notes, "gets us started."

Dr. Korenstein and one of the article's coauthors received support from the Commonwealth Fund. The coauthor is also supported by a Veterans Affairs Health Services Research and Development Service Career Development Award.

Arch Intern Med. 2012;172:171-178. Abstract, Editor's Note extract

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