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Stubborn Underuse and Overuse Are Global Healthcare Problems

Analysis  |  By Tinker Ready  
   January 12, 2017

Overuse and underuse are persistent symptoms of a profoundly dysfunctional healthcare system immune to incremental reforms, say the authors of an exhaustive study.

The overuse of health services is old news. In the US, the problem emerges in the form of variations in practice patterns and overdiagnoses. Here, underuse usually falls under the heading of access.

In both cases, efforts are underway to expand coverage and discourage the use of low-value services.

But the worldwide problem of inappropriate care described in a series of research papers released Monday goes beyond anything that could be addressed through quality measures or The Affordable Care Act.

The 27 researchers who contributed to the series published in The Lancet see overuse and underuse as symptoms of a profoundly dysfunctional healthcare system immune to incremental reforms.


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They make their case in a series of four articles that describe the problem, identify causes, and call for systemic change. They sum up their findings this way: "Because poor care is ubiquitous and has considerable consequences for the health and well-being of billions of people around the world, remedying this problem is a morally and politically urgent task."

In a related commentary, Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, describes the research as a "call-to-arms to improve health care globally by better matching care to needs, and practice to science."

The authors met on Monday in London to discuss the findings. One of them, Lown Institute president Vikas Saini, MD, spoke to HealthLeaders Media last week in his organization's Boston-area office.

The Lown Institute, which inspired and shepherded the research, is working to spark a grassroots movement "to transform the health system," he said.

"One of the things we recognized through the work of the papers, which I don't think we would have recognized without it, is that overuse and underuse occur all around the world," Saini said.

The findings on inappropriate care are staggering.


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Some are familiar: The WHO estimates 1.5 million children died of vaccine-preventable illnesses in 2015.

Others findings may be unfamiliar: Hypertension is considered undertreated in the US, where 70% of Americans with hypertension are treated. In sub-Saharan Africa, only 18% receive treatment.

And the lists go on: 500,000 cases of faulty thyroid cancer diagnoses. Excessive antibiotic use in China. Inappropriate hysterectomies and colonoscopies in the US. Unneeded knee replacements in Spain and 6.2 million excess caesarean sections each year—half in Brazil and China.

In France, China, and Cameroon, researchers cite the underuse of anticoagulation drugs in certain patients at high risk of stroke.

Who's to Blame?
Causes of this misdirected care are many, according to the study authors. But they cite three overriding drivers – money, knowledge, and power.

The commercial nature of healthcare is high on the list and the authors are not afraid to use the word "greed" to describe the motivations of for-profit players.

In some cases, underuse is driven by patients, who don't seek or comply with care. Another well-know driver, healthcare financing schemes, often influence provider and hospital behavior.

Yet another driver is the lack of planning, Saini said.

"Hundreds of millions of dollars are devoted to health resources: buildings, hospitals, training of physician and nurses," he said. "Yet, there is remarkably poor clarity on how to figure out what you really need. What does your population need?"

In India, for example, poor care comes from a push to move childbirth into new hospitals instead local birthing centers, which are less expensive and just as safe, Saini said.

In order to address all this, the Lown researchers envision a healthcare system that will be very different than the one we have now. Hospitals will need to find what Saini calls a "glide path" that will allow them to adapt.

"In the end, a highly efficient healthcare system is going to need less hospital care and a lot more outpatient, preventative, primary and in-home care," he said. "People who think deeply and hard about health care see that. Everyone is stuck with the transition. How do we get there?"

Saini believes it will take universal coverage and global payments to hospitals to address the problem. But, he said it will take more research, experimentation, and a political movement to bring about change.

It's About Power
"Care delivery is the net result of the relative power of various stakeholders to influence the process of decision making in the doctor/patient relationship," Saini and his co-authors write.

"Stakeholders with sufficient economic capital can use that ability to financially support and influence others, and reinforce terms most favourable to their interests."

He is convinced that change will not happen without the kind of activism and buy-in he thinks was absent in the run-up to the Affordable Care Act.

"The allocation of healthcare is such an important issue around the world, it really does require a greater engagement on the part of the public in order to come to an understanding of what kind of solutions are going to be appropriate and acceptable to people," he said.

Without it, he said, "We'll see change. We'll see improvements, but not enough to move the needle."

Tinker Ready is a contributing writer at HealthLeaders Media.


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