Right-Sizing Care: Lessons for Pediatrics

Laurie Scudder, DNP, NP


June 01, 2016

Underuse: The Less Noticed Problem

Medscape: We've been talking about overuse. But what about underuse?

Dr Schroeder: Certainly, underuse is a problem, too. Right Care is about getting not too much care, but also not too little care. It is important when we have these discussions to have some equipoise and make sure that we are looking at both sides of this issue. The two of us have gravitated a little bit more toward the overuse side over the past couple of decades in discussions of US healthcare, but it certainly doesn't mean that underuse isn't a problem.

An important, common theme at Lown is to always keep in mind that healthcare is just a very small fraction of overall health. Understanding and addressing the social determinants of health will probably go a lot farther than a focus on testing and medical interventions. We spend a lot more on healthcare, but a lot less on some of the social services that probably play a very large role in improving the health of the population.

Dr Quinonez: And that is a harm, too, right? If you're spending so much money on things that are of little or questionable benefit to patients, could you be using those resources on things that are probably more important, such as social services, housing, and nutritious food? It is important to point out underuse as well, because there are so many things that we know work that we're probably not using in favor of these newer things that we think are going to create benefit, but often don't.

Medscape: What are the primary messages you took away from this meeting that you wish to share with your colleagues?

Dr Schroeder: I think we must help patients, families, and healthcare providers understand that detection of abnormalities is not always synonymous with patient benefits. Just because you found something doesn't mean that it was good that you found it. Ricardo brought up cancer screening. It's pretty rare to hear someone say, "I wish we hadn't found that cancer." But when you look rigorously at the data, sometimes we find cancer that never would have caused harm. Or we find a cancer that led to interventions that are more aggressive than the cancer itself.

So that, to me, is one of the fundamental areas where we need to advance the discussion. It is to help people understand that finding things is not always beneficial.

Dr Quinonez: The meeting had some really innovative ways of looking at overuse. I'll tell you my example. I was struck by one of the poster sessions presented by Cho and colleagues[10] from the Icahn School of Medicine at Mount Sinai. They examined the issue of overuse as a medical error. That is an innovative way of looking at overuse, because arguably it is a medical error. It is something that is not benefiting the patient and that is unnecessary.

We traditionally think of a medical error as something that we do that directly harms the patient. Well, overuse also harms the patient, but that concept has not been elevated to the same level in our discussions. If we start looking at overuse as an error and make it a reportable event, just as we do other medical errors, we might drive some change. That was an innovative idea that was presented at that conference that might make this issue a higher priority.

Follow Ricardo Quinonez on Twitter: @QuinonezRicardo

Follow Alan Schroder on Twitter: @safelydoingless

Follow Laurie Scudder on Twitter: @LaurieScudderNP

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