Systematic overuse of healthcare services: a conceptual model

Abstract

A perfect storm of factors influences the overuse of healthcare services in the USA. Considerable attention has been placed on geographic variation in utilization; however, empiric data has shown that geographic variation in utilization is not associated with overuse. While there has been renewed interest in overuse in recent years, much of the focus has been on the overuse of individual procedures. In this paper we argue that overuse should be thought of as a widespread and pervasive phenomenon that we coin as systematic overuse. While not directly observable (i.e., a latent phenomenon), we suggest that systematic overuse could be identified by tracking a portfolio of overused procedures. Such a portfolio would reflect systematic overuse if it is associated with higher healthcare costs and no health benefit (including worse health outcomes) across a healthcare system. In this report we define and conceptualize systematic overuse and illustrate how it can be identified and validated via a simple empirical example using several Choosing Wisely indicators. The concept of systematic overuse requires further development and empirical verification, and this paper provides an important first step, a conceptual framework, to that end.

Fig. 1

A conceptual model of systematic overuse. The figure demonstrates how an index of overused procedures can be created to represent systematic overuse. If we consider all possible procedures, we would have those that are desirable (southeast quadrant), some that are not desirable (northwest quadrant) and those that would depend on a specification of an acceptable tradeoff between costs and outcomes (northeast and southwest quadrants). An index of procedures may contain a combination of interventions that may or may not be desired. If the index in aggregate is associated with higher cost and no health benefit (including adverse outcomes), then it would be consistent with the conceptualization of systematic overuse

Fig. 2

This figure demonstrates the correlation between costs and health outcomes of six Choosing Wisely indicators (blue diamonds). Of these, only two are consistent with the notion of systematic overuse (i.e., associated with higher costs and no health benefit/ poorer outcomes). When we construct an index of these six indicators and hold their individual specific characteristics constant, the resulting aggregate measure (red diamond) is strongly associated with higher costs and poorer outcomes (more so than any individual indicator). The numerical values on the x-axis and y-axis represent Pearson’s correlation coefficient (ρ)