Overuse of ambulatory services has not improved over past decade, report concludes

Although the delivery of underused care has significantly improved, a new decade-long analysis has found little improvement in reducing overused or inappropriate care in the ambulatory setting.

The study, published in the Archives of Internal Medicine reveals that overuse accounts for an estimated $280 billion of the $700 billion in annual waste across the U.S. healthcare system.

The review, conducted using data reported from 1999 to 2009, found significant improvement in six out of nine underuse measures, such as the use of antithrombotic therapy for atrial fibrillation and the use of aspirin, beta blockers, and statins in coronary artery disease.

Only two out of 11 overuse quality indicators showed improvement, however, with one becoming worse and eight unchanged over the course of the study. The sole areas of improvement were in the overuse of cervical cancer screening in women aged more than 65 years and in the overuse of antibiotics for asthma exacerbations. Rates of urinalysis testing at general medical examinations decreased slightly, but barely enough to be significant, the report notes.

Among the overuse measures that remained unchanged over the 10-year period studied were complete blood count and electrocardiogram testing in general medical examinations, the use of antibiotics for upper respiratory infections and acute bronchitis, mammography for women aged at least 75 years, imaging for acute back pain, and the performance of chest x-rays in general medical examinations.

In terms of inappropriate care, only three out of 13 measures showed improvement.

The study indicates that little improvement has occurred in the delivery of inappropriate care over the past decade, with problem areas including the use of prostate-specific antigen testing in olden men and cervical cancer screening in older women.

Targeting and reducing inappropriate care has not been a focus of the quality care movement, according to the report, despite efforts over the past 2 decades to measure healthcare quality.

“Despite the acknowledgement that overuse contributes to waste and inefficiency in our healthcare system, it is not routinely measured in quality assessments,” report authors note. “Reducing inappropriate care will require the same attention to guideline development and performance measurement that was directed at reducing the underuse of needed therapies.”

Reducing overused therapies is meeting with resistance, however, particularly in the political and cultural arena, the report authors note.

“The unwillingness of our society to address overuse to achieve both high-quality and affordability reflects the pervasive fear of rationing and the interests of industry stakeholders,” the report concludes. “Reducing healthcare costs and improving the quality of care in the United States can be achieved by reducing overuse and misuse of healthcare services, but it will require making uncomfortable decisions that patients, physicians, and policymakers have been historically unwilling to make.”