Reduce Harm and Waste - Overuse

The approach to Reducing Harm and Waste in Realistic Medicine is to focus on value. When resources are limited, interventions are offered to those who will benefit most and who are more willing to accept risk and in these conditions it is more likely that high value healthcare is delivered. However as resources increase, interventions are offered to those less likely to benefit while the likelihood and magnitude of harm stays the same and in these conditions it is more likely that low or negative value healthcare is delivered. A personalised approach to care can help communicate these concepts for patients and help understand what benefit and risk mean for a patient’s personal situation. Personalised care can also reduce the impact of adverse events. Being Open is a best practice framework used in Scotland which creates an environment where patients and families feel supported and healthcare professionals and managers have the confidence to act appropriately. “Psychological harm to families is reduced when they experience compassionate care, their perspective is valued and when they are central to the review of care.” Being Open has also been used to prevent future harm when staff participate with the learning and improvement generated from the adverse event review reports. [The Scottish Government. Personalising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2017-18. Published 2019. https://www.gov.scot/publications/personalising-realistic-medicine-chief-medical-officer-scotland-annual-report-2017-2018/pages/7/]

During the pandemic some healthcare services were scaled back in order to minimise harm. Also, people were reluctant to access services and it is of concern that they have chosen to stay away. Routine care has been delayed and is now becoming more urgent. The organisation and delivery of care will need to be reviewed as demand increases. Shared decision making and personalising care will help people make an informed choice about their care and allow effective and efficient use of services, reducing harm and waste. Modernising Patient Pathways Program (MPPP) is transforming outpatient services across Scotland by ensuring the optimal pathway is chosen at first point of contact. Active Clinical Referral Triage (ACRT) has the potential to reduce waiting times by eliminating unnecessary face to face appointments.  Discharge Patient-Initiated Review (PIR) encourages patient independence and helps to avoid unwarranted use of our clinical resources, as well as our patients' valuable time, by avoiding routine "check-ups”. [The Scottish Government. The Chief Medical Officer for Scotland’s Annual Report 2020-21: Recover, Restore, Renew. Published 2021. https://www.gov.scot/publications/cmo-annual-report-2020-21/ ]

Value can be assessed in many different ways and can include cost-effectiveness analysis, economic analysis, disinvestment, and reducing overuse and overprescribing. Below is a selection of recent journal articles and reports which are on overuse in healthcare.  If you are looking to answer a specific question please submit a literature search request at the link above.  If you would like to be alerted when new content is available here then please sign in and select Follow.  You are welcome to leave comments and suggestions below in the comments section.

The BMJ Too Much Medicine page provides an excellent timeline of evidence and examples of too much medicine.  There is also a digital theme issue of the BMJ on Overdiagnosis.

The Lancet has also published several articles on overuse and underuse called Right Care:  Available here

The Cochrane Collaboration also launched a new research group in December 2019 - Cochrane Sustainable Healthcare.

Articles:

HASANPOOR, E., et al, 2020. Using the evidence-based medicine and evidence-based management to minimise overuse and maximise quality in healthcare: a hybrid perspective. BMJ Evidence-based Medicine, 25(1), pp. 3-5.

PAUSCH M., et al, 2020. Is it really always only the others who are to blame? GP's view on medical overuse. A questionnaire study. PloS one, 15(1), pp. e0227457. This study aimed to capture the current opinion of German General Practitioners (GPs) to medical overuse.

ROWE, T.A., et al, 2020. Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement. Journal of General Internal Medicine,
To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.

ROWLAND, K., 2020. Choosing Wisely: 10 practices to stop-or adopt-to reduce overuse in health care. Journal of Family Practice, 69(8), pp. 396-400.

BORN, K., et al, 2019. Reducing overuse in healthcare: advancing Choosing Wisely. BMJ, 367, pp. 6317.

STORDAL K., et al, 2019. Overtesting and overtreatment-statement from the European Academy of Paediatrics (EAP). European journal of pediatrics, 178(12), pp. 1923-1927. Inappropriate testing and treatment may impose a risk. There is a large and unexplained variation in the use of tests and treatments for children between and within countries. This suggests that non-scientific factors determine their use. Examples from the medical literature of overtesting and overtreatment challenge us to reconsider current practices. Antibiotic overuse, overtreatment of bronchiolitis, and non-indicated radiological procedures are found in common practice across Europe. Choosing Wisely is an initiative to improve the quality of care by reducing unnecessary testing and treatment.

BORN, K.B. and LEVINSON, W., 2019. Choosing Wisely campaigns globally: A shared approach to tackling the problem of overuse in healthcare. Journal of General and Family Medicine, 20(1), pp. 9-12. “Choosing Wisely campaigns share a core set of principles, which inform how campaigns operate and engage with physicians, clinicians, patients, and other stakeholders. This article will address the origins and motivation of Choosing Wisely campaigns, and what factors have supported their spread. It will also discuss how leaders of Choosing Wisely campaigns are collaborating on shared priorities.”

BOUCK, Z., et al, 2019. Measuring the frequency and variation of unnecessary care across Canada. BMC Health Services Research, 19(1), pp. 446.
Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.

DEGELING, C., et al, 2019. Citizens’ juries can bring public voices on overdiagnosis into policy making. BMJ, 364(8186), pp. 236-238.
“Overdiagnosis challenges the social contract that underpins healthcare, and community voices are often missing from the relevant policy discussions. Citizens' juries elicit the voices, values, and preferences of informed citizens who are presented with evidence based expert views. Jurors deliberate the evidence among themselves before formulating their opinions and recommendations. Citizens' juries can elucidate public values that can then be used to inform policies and practices to manage the risks of overdiagnosis. The findings can contribute to guideline development and proposed changes to disease thresholds. The process of citizens' juries align with the basic tenets of evidence based medicine and can broaden and improve the dialogue around medical uncertainty.“

MORGAN, D.J., et al, 2019. 2019 Update on Medical Overuse: A Review. JAMA Internal Medicine,
A structured literature review identified 1499 candidate articles, 839 addressed medical overuse. Of these, 117 were deemed to be most significant, with the 10 highest-ranking articles selected by author consensus. The findings suggest that many tests are overused, overtreatment is common, and unnecessary care can lead to patient harm. This review of these 2018 findings aims to inform practitioners who wish to reduce overuse and improve patient care.

O'KEEFFE, M., et al, 2019. Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review. BMJ Open, 9(6), pp. e029540.
The aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services.

SCOTT, I.A., 2019. Audit-based measures of overuse of medical care in Australian hospital practice. Internal Medicine Journal, 49(7), pp. 893-904.
“This study aimed to assess the extent of overuse of care in hospital practice in Australia based on peer-reviewed literature that reported clinical audits using explicit measures of overuse applied to patient-level clinical data. Thirty-five studies met selection criteria, 14 relating to investigations, 21 to management strategies. Overuse rates above 30% were reported for coagulation tests, blood cultures, troponin assays, abdominal imaging studies, use of telemetry, blood product infusions, polypharmacy in older patients, prescriptions for various medications (gastric acid suppressants, direct oral anticoagulants, inhaled corticosteroids), admissions for low-risk chest pain and futile interventions in end of life care. Hospital physicians may need to audit their current high-volume practices and ensure they align with current criteria of appropriateness. “

SLAWSON, D. and SHAUGHNESSY, A.F., 2019. Reducing overuse by recognising the unintended harms of good intentions. BMJ Evidence-based Medicine, In this article, five cases are used to illustrate where harm can occur as the result of well-intended healthcare interventions.

Amin, EE., Ten Cate-Hoek, AJ., Bouman, AC., et al (2018)  Individually shortened duration versus standard duration of elastic compression therapy for prevention of post-thrombotic syndrome: a cost effectiveness analysis.  The Lancet Haematology 5(11):e512-e519.   Individually shortened duration of elastic compression therapy was cost effective compared with standard duration elastic compression therapy.  Use of an individualised approach to elastic stocking compression therapy for the prevention of post-thrombotic syndrome after deep vein thrombosis could lead to substantial cost savings without loss in health-related quality of life.

Chassin, MR et al. 1987. Does inappropriate use explain geographic variation in the use of healthcare services. JAMA 258(18):2533-7. The authors studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. They conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

Diao D, Wright JM, Cundiff DK, Gueyffier F. Pharmacotherapy for mild hypertension. Cochrane Database Syst Rev 2012;(8):CD006742. Authors’ conclusions: “Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”

Thorlund, JB., Juhl, CB., Roos, EM., et al. Anthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015;350:h2747. “The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.”