Defining inappropriate care

David Brooks penned an editorial yesterday about healthcare cost inflation and how the current health reform efforts do not go far enough in addressing this crucial problem. Cost inflation is indeed a big problem—this year’s 7.6% increase is the lowest in years yet is still staggering, amounting to a $1,162 increase in costs for families this year.


How do we reverse the cost curve? A look at the sources of wasteful spending can help clarify the problem and inform a solution. What follows is excerpted from a new report by Helen Blumen and Lynn Nemiccolo.


There are three types of inappropriate care that have a negative impact on quality and efficiency in the U.S healthcare system: overuse, underuse, and misuse of care.


Overuse of healthcare services occurs when the risk of providing a service exceeds the benefits of that service. Overuse also occurs when the benefits of additional services do not justify their costs. In the first instance, the services are inappropriate because they are ineffective. In the second, the services may be comparatively ineffective—that is, there may be alternative lower-cost services available that yield equal or better benefits. Studies have found that a significant percentage of certain surgeries and diagnostic procedures are performed despite their being clinically inappropriate. This conclusion was based on criteria developed using the available evidence base, supplemented by expert consensus. The overuse noted by the studies has serious negative consequences: overuse of procedures exposes patients to unnecessary risks of complications and increases healthcare costs without providing increased benefits.


Underuse of healthcare services occurs when services that are known to be medically beneficial are not provided. A study examining healthcare quality for acute and chronic conditions, as well as for preventive care, found that patients received about 50% of the recommended services. The explanation for why some recommended services were never received seems to lie in the perception of what medical conditions warranted treatment. The study found little difference in the proportions of recommended services received by category of services, but there was substantial variation depending on the clinical condition. For example, patients received recommended care for alcohol dependence only about 10% of the time, but they received recommended care for cataract nearly 80% of the time.  While underuse of healthcare services presumably costs less in the short term, obviously, correct curative treatment for acute conditions can prevent worsening of such conditions, thus reducing costs over the long term.


Misuse of healthcare services includes patient safety considerations, such as avoidable complications and medical errors. These include never events, such as operating on the wrong side of the body, and complications associated with healthcare, such as infections or pressure ulcers acquired during a hospitalization.


One of the root causes of inappropriate healthcare, resulting in less-than-optimal quality and efficiency, is variation in provider practice style. Practice style refers to the unique approach each physician takes when recommending care, especially when there is a lack of consensus about what care is best in a given situation. Part of the challenge for today’s physician is the sheer amount of scientific information and published articles created each year. Consider the volume of new medical research to emerge in the last 20 years alone. In 1989, the MEDLINE database reported 372,806 new published citations per year and 2,888 journals annually; in 2006, MEDLINE added 623,000 citations and 5,020 journals. Even the most conscientious physician could not keep up with such an explosion of new information.There also are cultural or style influences. Variances from best practices could be embedded in the way an organization dictates change of practice or they can simply be habit—the way physicians have always done things. Whatever the cause, individual variances lead to inconsistency in care decisions, sometimes resulting in inappropriate care.