A practical framework for understanding and reducing medical overuse: Conceptualizing overuse through the patient-clinician interaction

Medical services overuse is the provision of healthcare services for which there is no medical basis or for which harms equal or exceed benefits.¹ This overuse drives poor-quality care and unnecessary cost.^2,3 The high prevalence of overuse is recognized by patients,⁴ clinicians,⁵ and policymakers.⁶ Initiatives to reduce overuse have targeted physicians,⁷ the public,⁸ and medical educators^9,10 but have had limited impact.^11,12 Few studies have addressed methods for reducing overuse, and de-implementation of nonbeneficial practices has proved challenging.^1,13,14 Models for reducing overuse are only theoretical¹⁵ or are focused on administrative decisions.^16,17 We think a practical framework is needed. We used an iterative process, informed by expert opinion and discussion, to design such a framework.

The authors, who have expertise in overuse, value, medical education, evidence-based medicine, and implementation science, reviewed related conceptual frameworks¹⁸ and evidence regarding drivers of overuse. We organized these drivers into domains to create a draft framework, which we presented at Preventing Overdiagnosis 2015, a meeting of clinicians, patients, and policymakers interested in overuse. We incorporated feedback from meeting attendees to modify framework domains, and we performed structured searches (using key words in Pubmed) to explore, and estimate the strength of, evidence supporting items within each domain. We rated supporting evidence as strong (studies found a clear correlation between a factor and overuse), moderate (evidence suggests such a correlation or demonstrates a correlation between a particular factor and utilization but not overuse per se), weak (only indirect evidence exists), or absent (no studies identified evaluating a particular factor). All authors reached consensus on ratings.

Framework Principles and Evidence

Patient-centered definition of overuse. During framework development, defining clinical appropriateness emerged as the primary challenge to identifying and reducing overuse. Although some care generally is appropriate based on strong evidence of benefit, and some is inappropriate given a clear lack of benefit or harm, much care is of unclear or variable benefit. Practice guidelines can help identify overuse, but their utility may be limited by lack of evidence in specific clinical situations,¹⁹ and their recommendations may apply poorly to an individual patient. This presents challenges to using guidelines to identify and reduce overuse.

Despite limitations, the scope of overuse has been estimated by applying broad, often guideline-based, criteria for care appropriateness to administrative data.²⁰ Unfortunately, these estimates provide little direction to clinicians and patients partnering to make usage decisions. During framework development, we identified the importance of a patient-level, patient-specific definition of overuse. This approach reinforces the importance of meeting patient needs while standardizing treatments to reduce overuse. A patient-centered approach may also assist professional societies and advocacy groups in developing actionable campaigns and may uncover evidence gaps.

Centrality of patient-clinician interaction. During framework development, the patient–clinician interaction emerged as the nexus through which drivers of overuse exert influence. The centrality of this interaction has been demonstrated in studies of the relationship between care continuity and overuse²¹ or utilization,^22,23 by evidence that communication and patient–clinician relationships affect utilization,²⁴ and by the observation that clinician training in shared decision-making reduces overuse.²⁵ A patient-centered framework assumes that, at least in the weighing of clinically reasonable options, a patient-centered approach optimizes outcomes for that patient.

Incorporating drivers of overuse. We incorporated drivers of overuse into domains and related them to the patient–clinician interaction.²⁶ Domains included the culture of healthcare consumption, patient factors and experiences, the practice environment, the culture of professional medicine, and clinician attitudes and beliefs.

We characterized the evidence illustrating how drivers within each domain influence healthcare use. The evidence for each domain is listed in Table 1.