Background
Methods
CIS methods
Stakeholder engagement
Results
Rationale and Context (n = 179) | Process (n = 158) | Implementation (63) | |
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Years published | 1990–1999 = 12 2000–2009 = 31 2010–2016 = 136 | 1990–1999 = 9 2000–2009 = 27 2010–2016 = 122 | 1990–1999 = 1 2000–2009 = 10 2010–2016 = 52 |
Study type | Research = 78 Non-research = 101 Systematic review = 13 Cross sectional = 12 Qualitative study = 21 Case study = 17 Mixed methods = 9 Cohort study = 1 Interrupted time series = 1 Other research = 4 | Research = 90 Non-research = 68 Systematic review = 14 Cross sectional = 12 Qualitative study = 17 Case study = 25 Mixed methods = 9 Cohort study = 1 Interrupted time series = 1 Before and after = 1 Other research = 8 | Research = 45 Non-research = 18 Systematic review = 8 Cross sectional = 5 Qualitative study = 7 Case study = 12 Mixed methods = 3 Interrupted time series = 4 Before and after = 1 Other research = 5 |
Country focus | Australia = 33 Canada = 28 United Kingdom = 57 United States of America = 66 Spain = 14 Netherlands = 4 New Zealand = 4 Italy = 6 France = 5 Germany = 5 Ireland = 2 Denmark, Japan, Sweden, Switzerland, Austria, South Korea = 1 | Australia = 19 Canada = 33 United Kingdom = 41 United States of America = 68 Spain = 11 Netherlands = 2 New Zealand = 6 Italy = 5 France = 2 Germany = 2 Ireland = 1 Norway, Denmark, Japan, Sweden, Switzerland, Austria, South Korea = 1 | Australia = 8 Canada = 19 United Kingdom = 20 United States of America = 20 Spain = 3 Netherlands = 1 New Zealand = 3 Italy = 4 Israel = 2 Sweden = 3 South Korea = 2 France = 1 Switzerland = 1 |
Framework for addressing overuse of health services
Rationale and context for why overuse is prioritised to be addressed in health systems
Level | Considerations | Explanation |
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Societal | • Culture of ‘more is better’ | • The idea that ‘more is better’ permeates all aspects of society, including healthcare, which contributes to clinicians and patients to often opt for more tests or procedures, or take more drugs |
• Market forces | • Market forces that create increased demand for products and often exist without a counteracting force that makes the case for why more is not always better | |
Clinician | • ‘Better safe than sorry’ approach to care | • There is a prevailing culture of thoroughness and ‘better safe than sorry,’ which can mean ordering unnecessary tests ‘just to be sure’ |
• Acknowledgement of the issue and blame avoidance | • Some specialties have difficulty acknowledging that a service, test or procedure in which they have a vested interest may be overused • When provider groups have been asked to create lists of low-value services, they tend to include recommendations for other clinicians about what to do (or not to do) rather than address overuse by themselves and their colleagues | |
• Ability or willingness to change established ways of providing care | • As established in the behaviour-change literature, changing the way clinicians practice can be difficult and takes time | |
Patient | • Perception that clinicians that do more are better | • Receiving a test or treatment, even if it does not offer measurable benefits, is often seen as needed as the logical end point of an interaction between a patient and clinician |
• Demand for tests (e.g. from ‘well-informed’ patients) that are not evidence based | • Patients may not believe that their particular service, test or procedure is of low value and, when they are ill, disregard efforts to address overuse that are ‘for the greater good’ • While the information presented by patients to their clinician may be accurate, they may not be fully informed about what they need and hence many demand too many services and/or services that are inappropriate | |
• Citizen/patient health literacy | • Limited health literacy is a barrier to understanding health information and necessary alternatives, which can lead to the overuse of health services such as emergency room visits and hospitalisations | |
• Patients are not always consulted in decision-making processes | • Patients are often not engaged, or are engaged too late in the process and, as a result, do not fully understand, appreciate or agree with the decisions being proposed by their provider |
Type of system arrangement | Factor | Explanation |
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Delivery | • Limited training or preparation of clinicians to contribute to addressing overuse | • Most healthcare providers currently do not have the necessary skills to have the conversation regarding procedures that may be unnecessary or harmful to the patient |
• Limited time with patients | • Healthcare providers continually state that time constraints with patients is a barrier for practicing shared decision-making and explaining the reasoning behind not ordering specific health services | |
• Fragmented delivery of services across the system | • Patient information may not be shared effectively across providers, leading to duplicate and unnecessary testing for patients leading to inefficient care | |
• Co-dependency of service delivery | • It is challenging to withdraw resources from one health service without affecting others which are supplemental or dependent on the service being withdrawn from | |
Financial | • Financing systems | • Many health insurance cost-sharing approaches are applied to all services, regardless of clinical benefit • Identifying the correct balance within cost-sharing is difficult • High out-of-pocket spending may reduce the use of high-value services, while low out-of-pocket spending may lead to the overuse of unnecessary services |
• Remunerating clinicians | • Fee-for-service remuneration incentivises the provision of services, regardless of their value, and providers may be reluctant to reduce their use as their income will be negatively affected • Physicians also lack incentives to ration services | |
• Purchasing products and services | • The use of financial ‘levers’ to address overuse is only helpful in specific contexts (e.g. withholding funding for specific health services that are harmful), and are far too simple to be used to address the overuse of services that may provide minimal or no benefit for certain subgroups, but that may benefit others, or that may be more expensive or cost-ineffective, but are valued by some patient subgroups | |
Governance | • Role clarity in the system | • Many providers do not see themselves as resource stewards and therefore often do not consider or discuss the financial implications of ordering various tests, treatments and procedures with patients |
• Tension between autonomy and accountability | • While clinicians and organisations are given autonomy to decide which services are necessary, there is also a need for accountability measures to be put into place to enforce appropriate use | |
• Stewardship and authority | • Overlapping authority on different governmental levels make withdrawing from services difficult • Leadership to tackle the issue may be lacking |
Processes and approaches to addressing overuse
Elements | What it could include | Examples |
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Transdisciplinary approaches to identify health services that are overused | • Use the best available data, research evidence and guidelines to identify overuse of health services | Different approaches exist to use existing evidence to identify areas of overuse; for example, in the United Kingdom, NICE creates ‘do not do’ recommendations. This is done by advisory bodies using health technology assessments to identify areas of practice that are ineffective or lack sufficient evidence to support their continued use [76] |
• Conduct jurisdictional scans to identify health services that have been delisted due to overuse in other health systems using evidence-based processes and determine whether the same services are still being used locally | Various examples of conducting jurisdictional scans were reported in the literature, e.g. the EuroScan network is a collaborative, global network which conducts healthcare horizon scanning for health technologies. Its use revealed that approximately a quarter of technologies introduced into the health systems surveyed could be removed, as they are substitutes for already existing technologies [77] | |
• Identify health services that should be prioritised for full or partial removal from the health system through stakeholder- and consumer-engagement processes | Stakeholders can be engaged in a multitude of ways; for example, across seven programmes for identifying ineffective health technologies at different levels, stakeholders were involved in all programmes, either as consultants, or as part of an advisory panel or working group [78] | |
Stakeholder-led initiatives to address overuse | • Foster better communication and shared decision-making between providers and patients based on evidence-based recommendations and best practices | One example of an initiative to increase communication and shared decision-making is the Choosing Wisely campaign, which develops lists of “things patients and physicians should question”; by using this terminology instead of stating what not to do, respectful dialogue about informed choice-making is promoted between physicians and patients [79] |
• Change provider behaviour to address inappropriate use of health services in their practice | Different interventions have been developed to change provider behaviour such as guidelines, training sessions for primary care physicians, cost displays and order form changes [80] | |
• Educate patients/citizens about what health services they need (e.g. through decision aids) | Educating the users can assist in reducing overuse; for example, educating consumers can reduce the overuse of unnecessary and at times harmful medications [81] | |
• Develop mass-media campaigns to raise awareness about the need to address overuse | Mass media campaigns that target the public and increase awareness can be used effectively; for example, a mass media campaign to reduce the use of antibiotics reduced retail pharmacy antibiotics by 3.8% and managed care-associated antibiotic dispenses by 8.8% [82] | |
Government-led initiatives to address overuse | • Revise lists of publicly financed products and services | Revising lists of publicly funded services to remove services that are of low-value; for example, in Spain, low-value technologies are limited by level of reimbursement, frequency of use or restriction by patient or provider type [83] |
• Modify remuneration for providers or incentivise consumers to prioritise the use of some products and services over others | Incentives with outcome monitoring on the supply side reduce the use of low-value care through partial capitation or shared savings; value-based insurance design is one of the processes used to increase co-pay on services that are likely to be unnecessary [84] | |
• Require prior authorisation for use of specific health services that are identified on a list of overused services | Both demand and supply-side interventions need to make using low-value health services financially unwise or difficult to use without authorisation. This includes service specific interventions such as pay for performance, prior authorisation and population-based interventions, such as risk sharing, where providers accept financial responsibility for total costs of care [27] | |
• Engage stakeholders and consumers in decision-making processes | Giving stakeholders a voice will ultimately enforce their support for whatever result is reached, even if it was not their preferred one [85]. Relevant methods include consensus techniques, coverage design, integrating the evidence from systematic reviews with social values and preferences, and prospective data collection [41] |
Implementation considerations
Categories | Barriers | Explanation |
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Patient/public level | • Online information | • Patients have access to websites and advertisements of varying quality that may lead them to asking for tests or procedures that they do not need |
• Resistance: not consulted early enough | • The shared decision-making process needs to be perceived as legitimate and transparent, especially by the public; however, the level of public involvement may vary, depending on the nature of the decision and the personal preferences of members of the public | |
• Resistance: may not want services rationed | • The natural inclination of people (patients and clinicians alike) is to perceive a greater disadvantage from the withdrawal of an already existing service as opposed to the denial of a new service of similar value; additionally, patients may feel entitled to services that have been available in the past | |
• Funded by interest groups | • Some patient groups may be funded by the manufacturers of drugs and technologies, and these groups could influence stakeholder- and consumer engagement processes to identify overused health services | |
• Lack of information | • Some patients may not feel sufficiently informed to properly contribute to the shared decision-making process | |
Clinician | • Obtaining agreement from providers regarding what is unnecessary | • Some providers may not be aware of or agree with the services that have been identified as overused and they may view the service as necessary, which could be the result of many reasons such as publication bias (i.e. where they read mostly what should be done and not what should not) or industry pressure where more is viewed as better |
• Providers may resist the encroachment on autonomy and income | • Providers, even if they do understand about overuse and its implications, may still be reluctant to accept limitations on their service use as this goes against their financial incentives, as well as against patient choice and provider autonomy to decide which treatment options are best | |
• Providers may view this as a passing fad | • Providers may perceive these initiatives as just another passing fad, and therefore may not invest energy in them | |
• May focus on low hanging fruit or other specialties | • Providers may not want to withdraw funds from services within their specialty, and therefore will only focus on low-hanging fruit or shift responsibility to other specialties and their overuse | |
Organisation | • May have competing interests | • Some organisations may have competing interests and priorities and therefore may resist collaborating with such an initiative |
• May need extra resources | • Organisations may view such an initiative as requiring extra organisational resources (e.g. shared decision-making requires more time with patients and hence more resources) | |
• Fatigue due to too many initiatives | • Some organisations may be experiencing fatigue (e.g. some organisations and their management may be tired of new ideas so there may be resistance to implementing another new initiative) | |
• Lack of infrastructure | • Some organisations may not have the infrastructure to implement the necessary changes | |
Health system | • Lack of awareness | • Some health system leaders may not be aware of the issues and the potential negative outcomes of the overuse of health services |
• Lack of political will | • Some health system leaders may lack the political will to address the overuse of health services | |
• Coordination between levels in the health systems | • Building consensus between stakeholders and different levels of government will be challenging, which will make coordination at a national level challenging | |
Lack of evaluation/evidence | • Lack of evidence that certain tests/treatments are being overused | • There is a lack of evidence and published literature that clearly demonstrate that existing health services provide little or no benefit, and at times cause harm • The data to demonstrate that there is overuse does not always exist or is not always easily accessible |
• Lack of information that certain organisations or providers are actually overusing the service | • Stronger evidence and access to data is needed to demonstrate overuse across providers, organisations and jurisdictions | |
• Lack of belief that the current evidence is correct (i.e. when physicians are presented with variations of care, they question the evidence) | • When presented with evidence of overuse, many providers challenge the evidence base and are resistant to accept the results |