Right Care Series in The Lancet
Abstract: A global effort to assess the scope of overuse and underuse and expose these twin failings at the center of health strategies everywhere.
With the Right Care Series, published by The Lancet in 2017, the Lown Institute launched a global effort to assess the scope of overuse and underuse and place these twin failings at the center of health strategies everywhere to achieve the right care for all people. The Institute organized a team of 27 international experts from nine countries and 21 institutions.
Heralded as “stunning scholarship” by Don Berwick, MD, former administrator of the U.S. Centers for Medicare & Medicaid Services, the Series consists of four papers and three commentaries.
The project was a response to the success of the Lown Institute’s Avoiding Avoidable Care conference in April 2012, the first major medical conference specifically addressing the issue of overuse, or unnecessary medical services. Since then, overuse has become a major topic of scientific and policy discussion. The Lown Institute has now adopted the more comprehensive framework of “right care,” incorporating the problem of underuse, or failure to deliver needed care to patients, into a series of four papers about health care delivery around the world.
Inappropriate care is a widespread phenomenon
Doctors continue to underuse simple and inexpensive interventions, and to overuse ineffective but familiar, lucrative, or otherwise convenient services, despite potential patient harms. Meanwhile rising health costs are straining the budgets of families and governments globally, forcing health ministers and providers to focus on overuse. At the same time, underuse continues to plague both rich and poor countries. These two issues can affect the same country, the same health organization, the same hospital, and even the same patient.
Overuse and underuse of medical procedures are very common
A substantial fraction of medical services worldwide is unnecessary or ineffective. Even common procedures with clear guidelines for use are routinely performed inappropriately. Underuse of effective treatments is also common globally, even in countries where citizens are well-insured. Across nations, ineffective, scientifically- unwarranted care amounts to about ¼ of the total volume of services. In a 2013 report, more than 400 million people around the world lacked access to basic health services such as HIV treatment and vaccination against common childhood illnesses, and a recent study in Australia found that adults received appropriate care only 57% of the time.
Overuse is not limited to rich countries, and underuse is not limited to poor countries.
For example, imagine a homeless diabetic man living in a major American city, without access to primary care. He becomes confused due to high blood sugar and is taken to the emergency department, where he has a head CT. The scan is normal, but happens to show something on his thyroid gland in his neck. While it’s almost certainly unrelated to why he’s in the hospital, he is diagnosed with a possible thyroid cancer. Needle biopsies are performed and the condition is slow-growing and nonlethal, but he has thyroid surgery anyway. This man’s care has included clear underuse of effective primary care to manage his diabetes, as well as likely underuse of social support services to help him find stable housing. However, he has also been a victim of likely overdiagnosis (diagnosing a thyroid tumor that was unlikely to ever cause symptoms) and overtreatment.
Alternatively, consider New Delhi in India: it has built multiple enormous cardiac care hospitals. While those hospitals will surely perform some valuable procedures and even save many lives, they will also perform many unnecessary cardiac surgeries that will not prolong life or improve its quality. Meanwhile, the city has teeming slums, where millions of people live, and where residents lack access to simple birthing facilities, basic primary care, or necessary emergency care. The resources dedicated to unnecessary and ineffective cardiac surgeries are not available to provide basic services that are needed just next door. This grossly unequal allocation of resources is a major contributor to overuse and underuse, and is emblematic of how overuse steals resources that are desperately needed for other effective interventions.
Overuse is harmful because all medical procedures carry some risk; underuse is harmful because it leaves illness and suffering untreated
In the US alone, preventable medical harm is linked to hundreds of thousands of deaths each year, making it one of the most common causes of death. Thousands more patients experience complications from medical care, much of which is attributable to unnecessary testing and treatments. For example, about 14,000 Americans are harmed annually in the course of undergoing an inappropriate knee replacement, suffering from systemic infection, heart attack, stroke, and in some cases death. Such harm occurs because all medical procedures carry not only risk from errors and false positive tests, but also some unavoidable side effects. Overuse also wastes resources, including labor, infrastructure and money that could be better used to address unmet health needs.
The harm from underuse is similarly clear: Patients suffer and die from conditions that are treatable. In many low-income countries, for example, maternal mortality rates are far higher than in developed countries due to lack of infrastructure. Given adequate resources, most of those maternal deaths are preventable.
There are multiple causes of overuse and underuse, and no single solution will fix the problem
A wide range of research has explored why systems deliver poor medical care. Universal health coverage is an essential element to good care, but no matter how health care is funded, financial incentives are among the most important drivers of care patterns. The Lancet Right Care Series finds that overuse tends to occur for services that generate revenue while underuse is usually driven by the absence of powerful business models. Research shows that there are dozens of other causes of overuse and underuse, including cultural beliefs (within medicine and in the broader culture), common cognitive biases, commercial interests, the limits of medical evidence, and how clinicians deal with uncertainty. Addressing these drivers will require significant changes in financial arrangements, medical education, regulation of commercial health care entities, and how care is provided.
Getting the public involved in health care decisions
Health systems around the world are experimenting with new payment systems, organizational models, and better use of evidence in order to reduce overuse and underuse. Such efforts have had varying degrees of success, but controlling costs and improving the quality of health systems cannot be accomplished without acknowledging a fundamental truth: Health care is a social good, which should be seen and treated as one part of promoting health, along with socio-economic determinants and public health. Achieving that goal will require a more socially-minded and less transactional approach to medical practice. Reforming the delivery of care will also require political will. In order to get to the right care, communities and societies must make decisions collectively and democratically about how to spend societal resources to achieve health.
A movement for right care
To get the right care, we need to reorganize health care systems, and to organize in communities across our countries. That’s why the Lown Institute founded the Right Care Alliance, a network of doctors, nurses, patient activists and civic leaders dedicated to creating public demand for the right care. To learn more about how you can get involved with the Right Care Alliance, go to www.rightcarealliance.org or email firstname.lastname@example.org.