In a series of papers and comments published in The Lancet, Vikas Saini, and his colleagues provide a framework for thinking about how to address the inequities in the provision of affordable healthcare to people. The analysis addresses inequity in both high-income countries (HICs) as well as low and middle-income countries (LMICs). Their hope is to spark “serious discussions about what kind of health system we want for the 21st century as part of our commitment to universal health coverage.” They believe that overuse (the provision of medical services that are more likely to cause harm than good and underuse (the failure to use effective and affordable medical interventions) of medical services takes away from “right care.”
“In its simplest definition it (right care) is care that weighs up benefits and harms, is patient-centred (taking individual circumstances, values, and wishes into account), and is informed by evidence, including cost-effectiveness.”
In the paper that focuses on evidence for overuse of medical services, the authors Brownlee and her colleagues make a distinction between services that are clearly and universally beneficial when used on the right patient and services that are definitely inappropriate. However, they point out, most services lie within a “grey zone” where the risk-benefit profile varies widely depending on the patient (e.g. antidepressants for adolescents). Moreover, decision making in providing these services is often based on physician assumptions and biases rather than being grounded in client preferences. They report on overuse measured in two ways – directly through registries and medical records and indirectly, through geographical variation in service utilization that is not linked to the populations serviced.
The authors link overuse of services to overdiagnosis. This refers to the process by which an illness label is assigned to a condition that will not progress if left untreated. It can occur as a result of screening tests, including those that are recommended screening procedures. Overdiagnosis is also linked to the narrowing the definition of health or, in other words broadening the definition of disease – also referred to as overmedicalization – for which the risk-benefit profile of treatment favors risk. An example of this is the lowering of thresholds to treat cholesterol.
Some of the findings highlighted in this paper are
- Antibiotics are the medication that are most appropriately overused in HICs and LMICs – for example in the Italy, 9% of children with acute diarrhea receive antibiotics inappropriately whereas in China 57% of patients do.
- There is a high rate of screening that is probably unrequired for cervical cancer, use of mammography and colonoscopy screening. In Korea, 99.7–99.9% of screen-detected thyroid cancers represent overdiagnosis, whereas in India there is evidence of inappropriate breast cancer screening.
- There is a lack of systematic analyses of inappropriate use of diagnostic tests but the ones of note that have been studied as overused are colonoscopy and endoscopy.
- Surgery is likely overused in HICs. Several cardiovascular procedures are overused worldwide.
- The rates of inappropriate hospital admission across the would ranges from 1% to 54%, which may represent an underuse of less aggressive treatments.
- Aggressive care is overused for end-of-life care, whereas palliative treatment is underused. About half of the people worldwide die in a hospital as a result even though a majority would prefer to die at home.
The authors comment on potential harms to patients and report that very few studies document harms related to overuse and most data is inferred from adverse events. Harms can be physical – for example the effects of inappropriate knee replacements – or psychological – for example increased stigma, depression and health-related anxiety as well as the effects of carrying an illness label. The negative effects of labeling, including overtreatment has been documented in the case of overdiagnosis of ADHD in the US. Finally, patients suffer tremendous financial harm as a result of being recommended services they do not need. In terms of health-care systems, overuse leads to perpetuation of worldwide health inequities, both within and across countries.
In conclusion, the authors note that even though evidence for overuse exists, there still exists the challenge of measuring it and studying it systematically.
Brownlee, S., Chalkidou, K., Doust, J., Elshaug, A. G., Glasziou, P., Heath, I., . . . Korenstein, D. Evidence for overuse of medical services around the world. The Lancet. doi:10.1016/S0140-6736(16)32585-5 (Abstract)