Research on overuse harms: Where do we go from here?

Over the past decade, research on medical overuse has expanded and improved, and awareness of overuse in the medical community has greatly increased. However, the idea that “more is not always better” in medicine has yet to fully permeate the public dialogue about health care in the U.S.

One reason overuse is not central to the health care debate is because the conversation on overuse tends to focus on costs rather than harms caused by overuse. While people care about reducing waste, it doesn’t spark the same urgency as knowing that people are being physically harmed by unnecessary care. We need to reframe overuse not only as an issue of waste but as an issue of safety. However, we know very little about the scope and magnitude of harm from overuse in the U.S.

“If it’s just about money, then neither patients nor clinicians are that motivated. But spending has been easier to measure than harms.” — Shannon Brownlee

How do we prioritize, conduct, and publicize research on overuse harms, to help patients, clinicians, and policymakers better understand that overuse is not just a “cost problem”? On August 26, 2019, the Lown Institute convened about 30 experts in overuse, including researchers, clinicians (primary care doctors and specialists), patients, educators, and journalists, to discuss how we move forward in research on overuse harms.

The meeting participants discussed the following questions:

Why is measuring the harms of overuse so hard?

There are barriers to research on overuse harms at every step. For some tests and procedures, it’s not easy to determine whether they were indicated or unnecessary. How do you measure the harms of overuse when measuring overuse itself is difficult? It’s also hard to measure true harm from procedures because the collection and reporting of harms is incomplete. When harms are recorded, they are often difficult to attribute (eg. was the harm caused by overuse or an underlying medical condition?). Finally, measuring the true harm from overuse often involves identifying the entire “cascade” of treatment caused by initial overuse, which is difficult to do.

What outcomes should we be measuring? 

Meeting participants identified several important outcomes for overuse harms research, including:

  • Hospitalization, mortality, rate of readmission
  • Non-fatal complications and injuries
  • Long-term health and mortality
  • Additional diagnoses/medicalization
  • Financial toxicity for the patient
  • Levels of harm in patient sub-populations
  • Anxiety and other psychological harms
  • Opportunity cost (time lost while at the doctor or hospital)
  • Harm caused by follow-up tests and events (the “cascade” of overtreatment)

What do we have to gain by emphasizing harms of overuse?

Often, clinicians or patients will want to do an unnecessary test or procedure “just to be safe.” More research on overuse will show that doing nothing can be the safer option. This information could be used to provide feedback to clinicians and hospitals about their rates of overuse-related harm, which may be more effective than just showing them levels of overuse. Emphasizing the harms of overuse can make overuse a more urgent problem in the public health care discourse, and could aid advocacy groups who are pushing for reform in this area. 

However, meeting participants disagreed on whether making overuse harms research public was beneficial. Some cautioned that emphasizing overuse harms could make patients distrust their doctor, which is not helpful for reaching shared decisions. Conveying the urgency of the problem without casting blame solely on clinicians will be a key communications challenge.

Where do we go from here?

Dr. Daniel Morgan, Associate Professor of Epidemiology and Medicine at the University of Maryland School of Medicine, and Dr. Deborah Korenstein, Internal Medicine Specialist at the Memorial Sloan Kettering Cancer Center, have taken the lead on writing a paper outlining what we need to conduct research on overuse harms. They will consider what data need to be collected when we study treatments and tests and how we can define outcomes in a way that is meaningful for patients.

Overall the meeting was a successful convening of people who are passionate about overuse, and helped move the discussion of overuse harms forward.

“This meeting represented a first effort to create a sense of urgency around the problem of harm from overuse — really just a toe in the water. It won’t be the last,” said Shannon Brownlee, Lown Institute Senior Vice President.