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Physicians' Persistent 'Overuse' of Care Continues

 |  By cclark@healthleadersmedia.com  
   February 01, 2013

Clinicians are getting better at providing patients with appropriate care, such as assuring coronary disease patients receive aspirin, beta blockers and statins. But they've done a poor job in reducing unnecessary, overused care, such as screening men 75 and older for prostate cancer, or screening women 66 and older for cervical cancer.

Those are conclusions in a special "Less Is More" paperpublished this week in JAMA Internal Medicine by Minal Kale, MD, of Mt. Sinai School of Medicine and research colleagues at the University of California San Francisco and San Francisco Veterans Affairs Hospital.

"In our examination of ambulatory health care services over 10 years, we found an improvement in six of nine measures of underuse (care) but (an improvement in) only three of 13 measures of inappropriate care (both overuse and misuse)," the researchers wrote.

They added that they find "considerable room for improvement in most of our overuse measures, a space in which the dual goals of high quality and reduced costs can be met."

For example, though there is good evidence that prostate cancer screening in elderly men and the infirm is not beneficial, "it continues to be performed at alarming rates. Despite being easily measured, this practice has not been evaluated as a potential performance measure or adopted by the Healthcare Effectiveness data and Information Set (HEDIS)."

 

The most likely explanation for continued overuse of non-beneficial, potentially harmful care is that reducing inappropriate care "has not been a real focus of the quality of care movement," despite efforts to reduce the estimated $280 billion that is spent each year on delivery of services "for which the risks exceed the benefits," they said.

The analysis looked at nine types of care classified as underused, 11 types of care classified as overused, and two types of care classified as misused between 1999 and 2009; 79,083 patient visits during the earlier period and 102,980 during the latter period.

Data was drawn from the National Ambulatory Medical Care Survey and outpatient statistics of the National Hospital Ambulatory Medical Care Survey.

For specific "overuse measures," the researchers found that in addition to prostate cancer screening in men greater than age 74, which went from 3.5% in 1999 to 5.7% in 2009, six other types of "overuse" care increased.

For example, screening EKG in adults during a general medical exam went from 6.1% in 1999 to 11.3% in 2009; screening x-ray in adults with a general medical exam went from 4.7% to 7%; screening with complete blood counts for adults during a general medical exam went from 22.3% to 37.9%; mammography for women over age 74 went from 2.1% to 2.6%; imaging for back pain in adults older than age 18 went from 19.1% to 22.8%; and antibiotics for an upper respiratory tract infection went from 37.8% to 40.2%.

In the misuse measures group, the researchers found an increase in inappropriate medications in the elderly rose from 6.5% to 7.2%.

This suggests "there has been little change in the delivery of inappropriate ambulatory care in the past decade," they wrote.

The researchers indicated that developing guidelines to reduce inappropriate care is difficult because there are no publicly reported databases or easily searchable hospital claims data files. "If a patient has an acute myocardial infarction, all that may be needed to determine whether a patient appropriately received an aspirin is the discharge diagnosis, inpatient medication list, and discharge medications."

In an accompanying editorial, Rita Redberg, MD, of the University of California San Francisco Department of Medicine, noted "It took many years for our system to get to this current complex and dysfunctional state and will clearly take some years to make real improvements. In some ways, we are the victims of our own success, because these problems come from the many more technologies, procedures, and treatments that are now available as well as the many different financing schemes.

"It is only more recently that we are realizing how many people are also being harmed by overtreatment."

She pointed to last September's Institute of Medicine's report "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America" as a helpful effort to reduce wasteful care.

"The IOM report cautions us that as we embrace advances in healthcare, we must remember that a number of what were thought to be advances turned out not to be beneficial, or even harmful, such as prostate specific antigen (PSA) screening or some breast cancer treatments."

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