The rate of health care overuse — the portion of
health care services where harms outweigh benefits — varies widely in the
United States, and the inappropriate use of procedures, tests and medications
is often problematic, according to researchers.
“There are three categories of quality problems in
health care: underuse is the lack of provision of necessary care, misuse is the
provision of wrong care and overuse is the provision of medical services with
no benefit or for which harms outweigh the benefits,” the researchers
wrote.
Using the Medline database, they identified 172 articles
from 1978 to 2009 that measured the rates of overuse of procedures (53
studies), diagnostic tests (38 studies) and medications (81 studies) in the
United States. In addition, they examined 18 unique therapeutic procedures and
24 diagnostic services, including 10 preventive diagnostic services.
Antibiotics used to treat upper respiratory tract
infections (URI) were the most commonly studied services (59 studies); coronary
angiography (17 studies) and carotid endarterectomy (13 studies) and
coronary artery bypass (10 studies) were also most common.
The overuse rates for antibiotics for URI ranged from 2%
to 89%. Rates for coronary artery bypass grafting were generally lower than 15%
and rates for coronary angiography were generally lower than 20%. The rate of
inappropriate carotid endarterectomy ranged from 1% to 33% before 2000 and was
lower than 11% in all studies published after 2000.
Over time, overuse of antibiotics for URI and carotid
endarterectomy declined.
Of the 26 diagnostic services assessed, the most
commonly assessed were upper endoscopy (seven studies), colonoscopy (four
studies), plain film radiography for URI (six studies), diagnostic imaging in
low back pain (five studies) and prostate-specific antigen testing (four
studies). The rates of overuse varied widely, according to the researchers.
For preventive services, overuse rates ranged from 7.6%
to 60.8%. Six articles examined cancer screening; overuse of colon cancer
screening was 8% in a VA study and 60.8% in a study of repeat screening
colonoscopy in primary care, the researchers wrote. The range of overuse rates
for prostate cancer screening with prostate-specific antigen was 16.1% to 36.1%
in three studies. Additionally, a study of Pap smears for cervical cancer
screening reported that 58% of ineligible women were screened. There were no
studies examining the overuse of screening mammography; the overuse rate of
mammography in women with a pre-existing breast cancer diagnosis was 29.9% in
one study.
“While rates of inappropriate use of a few specific
services such as antibiotics for URI, [coronary artery bypass grafting],
[carotid endarterectomy] and [coronary angiography] have been well described,
and there is evidence of overuse of some services has declined over time, there
are gaps in our understanding of the appropriateness of many other health
services,” the researchers wrote. “Expanding the evidence base and
establishing appropriateness criteria for a broader range of services could
help target and eliminate overuse in health care services, which could reduce
health care spending without adversely affecting the health of the
public.”
Disclosure: The researchers report no relevant
financial disclosures.