Addressing overuse of health services in health systems: a critical interpretive synthesis

Abstract

BackgroundHealth systems are increasingly focusing on the issue of ‘overuse’ of health services and how to address it. We developed a framework focused on (1) the rationale and context for health systems prioritising addressing overuse, (2) elements of a comprehensive process and approach to reduce overuse and (3) implementation considerations for addressing overuse.MethodsWe conducted a critical interpretive synthesis informed by a stakeholder-engagement process. The synthesis identified relevant empirical and non-empirical articles about system-level overuse. Two reviewers independently screened records, assessed for inclusion and conceptually mapped included articles. From these, we selected a purposive sample, created structured summaries of key findings and thematically synthesised the results.ResultsOur search identified 3545 references, from which we included 251. Most articles (76%; n = 192) were published within 5 years of conducting the review and addressed processes for addressing overuse (63%; n = 158) or political and health system context (60%; n = 151). Besides negative outcomes at the patient, system and global level, there were various contextual factors to addressing service overuse that seem to be key issue drivers. Processes for addressing overuse can be grouped into three elements comprising a comprehensive approach, including (1) approaches to identify overused health services, (2) stakeholder- or patient-led approaches and (3) government-led initiatives. Key implementation considerations include the need to develop ‘buy in’ from stakeholders and citizens.ConclusionsHealth systems want to ensure the use of high-value services to keep citizens healthy and avoid harm. Our synthesis can be used by policy-makers, stakeholders and researchers to understand how the issue has been prioritised, what approaches have been used to address it and implementation considerations.Systematic review registrationPROSPERO CRD42014013204.

Nurses’ Perceptions on the Overuse of Health Services: A Qualitative Study

“…In this age of technological advances and progress, and an insatiable need for information, there is growing evidence of overuse of low‐value health services (Ellen, Wilson, Grimshaw, & Lavis, ). Overuse of health services are services provided that carry more risk of harm than potential benefit and may be unnecessary due to their lack of definitive medical basis (Chassin et al, 1998; Institute of Medicine, ; Morgan et al, ).…”

More signals that overuse of healthcare is a pervasive problem contributing to health system waste

“…While measurement is essential for identifying and prioritising areas where quality improvement efforts are needed and for monitoring changes over time, further investigation to understand the drivers of overuse are required to inform the development of effective strategies for reducing overuse. A complex interplay of clinician‐, patient‐, societal‐ and system‐level factors contribute to the overuse of healthcare services . Reducing the overuse of healthcare services will require an understanding of these drivers and concerted effort by clinicians, policy makers, patients and consumers using multiple approaches to target these factors.…”

“…Reducing the overuse of healthcare services will require an understanding of these drivers and concerted effort by clinicians, policy makers, patients and consumers using multiple approaches to target these factors. It is likely that both ‘top–down’ and ‘bottom–up’ approaches will be needed to bring about change …”

“…Top–down approaches require governments, medical societies and private third‐party payers to take the lead in efforts to improve care and minimise unnecessary expenditure, for example, by revising lists of publicly funded services to remove those that are of proven low value, establishing authorisation processes for use of overused services and creating performance measures or indicators to benchmark and then audit the quality of care. Bottom–up approaches require patients, clinicians and healthcare system leaders also to take a lead in effecting change, for example, by increasing the use of evidence‐based shared decision‐making between clinicians and patients and increasing public awareness about high‐value care . Various strategies designed to change clinician behaviour to address overuse, such as use of audit and feedback, are also promising approaches that could be implemented more widely to effect change .…”

Shared decision making: How can it be helpful in reducing medical overuse due to medical misinformation mess?

“…Limitation in health systems resources is a key concern of health policymakers who aim to increase the quality of health care services . There are many factors that increase cost and decrease quality of health systems, but among the most challenging are overuse and the related problem of overdiagnosis .…”