Overuse of ambulatory care services continues to plague healthcare system

In a recent analysis of nationally representative data published in the Archives of Internal Medicine, a JAMA Network publication, significant improvement in the delivery of underused care was shown; however, the overuse of ambulatory healthcare services hardly changed between the years of 1998 and 2009.

“Given the rising costs of healthcare, policymakers are increasingly interested in identifying the inefficiencies in our healthcare system,” the report said. “The objective of this study was to determine whether the overuse and misuse of healthcare services in the ambulatory setting has decreased in the past decade.”

[See also: Study finds hospitals aren't complying with communication requirements]

Minal S. Kale, associate of General Internal Medicine with the Mt. Sinai School of Medicine in New York, along with her fellow authors, conducted an analysis using data from the 1998, 1999, 2008 and 2009 National Ambulatory Medical Care Survey (NAMCS) and the outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS). Both of these surveys are conducted annually by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

According to Kale, the study sample included 79,083 and 102,980 visits by adult patients at least 18 years of age in 1998 to 1999, and 2008 to 2009, respectively.

She found a statistically significant improvement in six of nine underuse quality indicators, including improvement in use of antithrombotic therapy for atrial fibrillation, and use of aspirin and statins in coronary artery disease. She also observed improvement in two of 11 overuse quality indicators, which included a statistically significant decrease in cervical cancer screening among women older than 65 years, as well as a reduction in the overuse of antibiotics for asthma exacerbations. However, there was an increase in one overuse indicator, prostate cancer screening in men older than 74 years. She observed no changes in the other eight quality indicators she studied.

“In our examination of ambulatory care in the United States, we found an improvement in most of the underuse measures but limited changes in the delivery of inappropriate care. This study didn’t include all of the quality measures, but just the ones we were able to measure in our specific data set,” said Kale. “I think it’s interesting because it really sheds light on the efforts made by the healthcare system towards making sure people get the care that is needed and beneficial, but very little attention is paid to the inappropriate or overuse of care – the care that is given that has little benefit or has some risk to the patient or healthcare system attached to it.”

Kale added that she believes theret are several factors that lead to the overuse of care and that both clinicians and patients play a role.

“We have a culture where more testing is always better. There’s also these incentives for physicians to do more testing, and I think patients can sometimes drive overuse in the fact that a lot of patients believe that if it can be tested, it should be because many don’t understand the potential risks to themselves,” said Kale. “This is also a symptom of a healthcare system that isn’t really well connected.”

[See also: Study shows hospitals making headway on quality, with a long way to go]

Kale said there needs to be more funding and research that examines the overuse of care, and that healthcare organizations should be more vigilant about creating situations where clinicians can have conversations with patients about the benefits and risks of certain health tests.

“We need research that answers the question: ‘what is inappropriate care?’ Developing clinical practice guidelines that define when care should not be delivered and performance measures to address inappropriate care are critical steps to advance the mission of increasing the value and efficiency of healthcare delivery,” said Kale. “It’s a big part of our culture that the newest technology is the best technology, but sometimes it isn’t.”