Medical overuse –delivery of tests and procedures that have little or no clinical benefit — is a huge problem in health care, and one that has gained much more attention over the past decade. But despite efforts to reduce overuse like Choosing Wisely, rates of low-value care have barely budged. Why?
In a recent piece in the BMJ, Shannon Brownlee, special advisor to the president at the Lown Institute, and Dr. Deborah Korenstein, chief of general medicine service at Memorial Sloan Kettering Cancer Center, argue that if we want to significantly reduce overuse, we have to make clinicians and the general public more aware of the harms of overuse. So far, much of the framing around overuse has focused on waste and inefficiency, but the idea of saving money is not a very strong motivation to avoid overuse. In fact, some efforts to reduce waste in health care have been seen as “rationing” by patient groups.
“Even the term low value care implies that cost is the most important aspect of overuse. Framing it as a problem of cost or resource utilisation has yet to move clinicians and patients to avoid it in any meaningful way.”
Shannon Brownlee and Deborah Korenstein, The BMJ
Why has the “less is more” movement focused more on waste than patient harms? Financial waste from overuse has been much easier to measure, while research on harm from overuse is sparse. Many of the harms caused by overuse, such as psychological and social harms, are rarely measured. “There are no national or international data on the total number of adverse events occurring in the course of delivering most non-indicated treatments, how many patients are involved, or the seriousness of the injuries,” write Brownlee and Korenstein.
Part of the difficulty is that a lot of harm from from unnecessary tests and screenings come not from the test itself but cascade events, which are difficult to track. Many low-value tests and procedures fall into a gray area because they are appropriate for some patients but not others; tracking harm from the just non-indicated procedures is a difficult task. Another method would be just to apply a rate of overuse to a rate of harm, but rates of harm are inconsistently reported in clinical trials.
Brownlee and Korenstein conclude, “It is time to reframe this problem in a way that truly engages both clinicians and patients. Until they have a clear understanding of all the downsides of overuse, they cannot contribute fully to decisions about the care they deliver or receive or to the creation of effective policy around healthcare improvement.”