Medical over-, underuse should be confronted globally

11 January 2017 | Gesondheid
A five-part series of papers on medical underuse and overuse, commissioned by The Lancet, and led by the Lown Institute in Boston, calls for health policy makers and pro­viders to take urgent action and expand research to tackle underuse and overuse together, factors leading to widespread poor health care across the globe. The papers, titled The Right Care Series, are authored by 27 international experts and are available online and at a special all-day launch event held at King's College London on January 9.

The series explores the scope, causes, consequences of, and potential remedies for underuse and overuse of health care around the world. Underuse leaves patients vulnerable to avoidable disease and suffering; overuse causes avoidable harms from tests or treatments, while simultaneously wasting resources better spent on services needed for health. Both can occur in the same country, same organization, or health facility, and even afflict the same patient. Getting better value from health care is a challenge common to all nations, regardless of economic status or social system, the authors conclude.

“Greed, competing interests and poor information are universal drivers that can form an ecosystem of poor health care delivery,” said Vikas Saini, MD, president of Lown Institute and a lead author. “Citizens all over the world need to understand these forces if they are to defend and promote their financial security, safety, health and well-being.”

The authors conclude that overuse and underuse, the failure to deliver needed care, are epi­demic around the world. ­Examples cited in the series include rates of ­inappropriate total knee replacements, 26 percent in Spain and 34 percent in the U.S.; and rates of in­appropriate hysterectomies, 20 percent in Taiwan and 13 percent in Switzerland.

A common tragedy in both wealthy and poor countries is the use of expensive and sometimes ineffective technology while low-cost effective interventions are neglected. Thus the C-section rates are soaring in many countries around the world for low-risk births while the simple use of steroids to prevent premature births has lagged for 40 years since the first evidence was published. Research indicates that up to 6.6 million C-sections around the world are excessive.

“Patients and citizens need to understand what's at stake here if their health systems fail to address these twin problems,” said Shannon Brownlee, MSc, Lown Institute senior vice president, another lead author. “In the U.S., we are wasting billions of dollars that should be devoted to improving the nation's health.”

In a companion editorial, Don Berwick, MD, president emeritus of the Institute for Healthcare Improvement and former head of the U.S. Centers of Medicare & Medicaid Services, affirms that the papers lay out a framework for a major new area of work to achieve better care and more sustainable costs.

He also urges health ­ministries and legis­latures to take action. “This landmark series on overuse and underuse constitutes a call-to-arms to improve health care globally by better matching care to needs, and practice to science.”

Writing in a commentary accompanying the series, Richard Horton, editor-in-chief of The Lancet, and Sabine Kleinert, senior executive editor, stressed “Global health leaders need to recognize the opportunity to eliminate poor care and provide right care as the answer to truly and sustainably achieve healthy lives and wellbeing for all.”

Adam Elshaug, PhD, co-director of the Menzies Centre for Health Policy, The University of Sydney, and senior fellow at the Lown Institute, was another lead author, along with Paul ­Glasziou, FRACGP, professor of evi­dence-based medicine at Bond University. Co-­authors of the papers are from such institutions as the World Bank, Harvard, Stanford, Dartmouth and the Organisation for Economic Co-operation and Development.



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