Understanding suitability of health care services difficult, may lead to overuse in US

Korenstein D. Arch Intern Med. 2012;172:1-8.

The rate of health care overuse — the portion of health care services where harms outweigh benefits — varies widely in the United States, and the inappropriate use of procedures, tests and medications is often problematic, according to researchers.

“There are three categories of quality problems in health care: underuse is the lack of provision of necessary care, misuse is the provision of wrong care and overuse is the provision of medical services with no benefit or for which harms outweigh the benefits,” the researchers wrote.

Using the Medline database, they identified 172 articles from 1978 to 2009 that measured the rates of overuse of procedures (53 studies), diagnostic tests (38 studies) and medications (81 studies) in the United States. In addition, they examined 18 unique therapeutic procedures and 24 diagnostic services, including 10 preventive diagnostic services.

Antibiotics used to treat upper respiratory tract infections (URI) were the most commonly studied services (59 studies); coronary angiography (17 studies) and carotid endarterectomy (13 studies) and coronary artery bypass (10 studies) were also most common.

The overuse rates for antibiotics for URI ranged from 2% to 89%. Rates for CABG were generally lower than 15% and rates for coronary angiography were generally lower than 20%. The rate of inappropriate carotid endarterectomy ranged from 1% to 33% before 2000 and was lower than 11% in all studies published after 2000.

Over time, overuse of antibiotics for URI and carotid endarterectomy declined.

Of the 26 diagnostic services assessed, the most commonly assessed were upper endoscopy (seven studies), colonoscopy (four studies), plain film radiography for URI (six studies), diagnostic imaging in low back pain (five studies) and prostate-specific antigen testing (four studies). The rates of overuse varied widely, according to the researchers.

For preventive services, overuse rates ranged from 7.6% to 60.8%. Six articles examined cancer screening; overuse of colon cancer screening was 8% in a VA study and 60.8% in a study of repeat screening colonoscopy in primary care, the researchers wrote. The range of overuse rates for prostate cancer screening with prostate-specific antigen was 16.1% to 36.1% in three studies. Additionally, a study of Pap smears for cervical cancer screening reported that 58% of ineligible women were screened. There were no studies examining the overuse of screening mammography; the overuse rate of mammography in women with a pre-existing breast cancer diagnosis was 29.9% in one study.

“While rates of inappropriate use of a few specific services such as antibiotics for URI, CABG, [carotid endarterectomy] and [coronary angiography] have been well described, and there is evidence of overuse of some services has declined over time, there are gaps in our understanding of the appropriateness of many other health services,” the researchers wrote. “Expanding the evidence base and establishing appropriateness criteria for a broader range of services could help target and eliminate overuse in health care services, which could reduce health care spending without adversely affecting the health of the public.”

Disclosure: The researchers report no relevant financial disclosures.

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