Systematic Overuse of Healthcare Services: A Conceptual Model

Abstract

A perfect storm of factors influences the overuse of healthcare services in the USA. Considerable attention has been placed on geographic variation in utilization; however, empiric data has shown that geographic variation in utilization is not associated with overuse. While there has been renewed interest in overuse in recent years, much of the focus has been on the overuse of individual procedures. In this paper we argue that overuse should be thought of as a widespread and pervasive phenomenon that we coin as systematic overuse. While not directly observable (i.e., a latent phenomenon), we suggest that systematic overuse could be identified by tracking a portfolio of overused procedures. Such a portfolio would reflect systematic overuse if it is associated with higher healthcare costs and no health benefit (including worse health outcomes) across a healthcare system. In this report we define and conceptualize systematic overuse and illustrate how it can be identified and validated via a simple empirical example using several Choosing Wisely indicators. The concept of systematic overuse requires further development and empirical verification, and this paper provides an important first step, a conceptual framework, to that end.

The Association Between Continuity of Care and the Overuse of Medical Procedures

“…First, overuse measures do not define procedures that should never be done but rather identify procedures that are often overused and serve as indicators of broader overuse in health care systems with specific practice patterns and resources. 24 Second, administrative-based measures of care continuity are commonly used but may not reflect multiple aspects of care coordination. 19,24 The measured mean COC index in this study is slightly lower than other continuity indices published for Medicare patients by ourselves and others (0.31 in this study vs 0.35–0.36 29 and 0.50–0.60 5 published elsewhere); however, other sources define study periods, episodes of care, and minimum numbers of patient visits differently, limiting the appropriateness of interstudy comparisons.…”

“…24 We operationalized overuse using items from a previously studied set of 19 potentially overused procedures, including 13 diagnostic, 3 therapeutic, 2 screening, and 1 monitoring procedures. 25 These measures were derived from publications of national professional societies and consumer groups with interests in quality improvement or cost-containment and were selected if they were obtainable from claims data and relevant for patients older than 65 years.…”

An Index for Measuring Overuse of Health Care Resources With Medicare Claims

“…Although the term overuse has existed in a medical context for over 400 years, 37 it remains an elusive concept. Moving the focus from single episodes of overuse to the broader concept of systematic overuse may be useful for researchers and policy makers and make health systems not only aware of this systemic problem, but responsible for addressing overuse across their entire organization.…”

“…We previously proposed that there is a latent tendency to overuse that pervades many health systems. 37 We hypothesize that use of these procedures collectively should result in a net cost to the health system, if the portfolio indicates systematic overuse (ie, the direct costs of these procedures should not be offset by cost savings elsewhere in the system). Specifically, we propose that pervasive overuse would impact a range of procedures across the entire system.…”

A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient‐Clinician Interaction

“…11, 12 To date, few studies have addressed methods to reduce overuse, and de-implementing non-beneficial practices has proven challenging. 1, 13, 14 Existing conceptual models for reducing overuse are theoretical 15 or focused at administrative decisions 16, 17 ; we believe a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.…”