Overutilization, Overuse or Waste?

My initial interest in doing clinical research arose from a belief that we are wired to “just do something” as physicians and an even stronger belief that I was somehow morally obligated to question this propensity to intervene.  I honestly never saw myself as searching for the cure for any disease; rather, I’ve always been searching for what we can safely avoid doing.  I know…sounds pretty lame, right? And yet, it gets me out of bed in the morning, and, as time goes by, I find that a profound antipathy toward overuse and waste motivates many pediatric hospitalists.  Odd that a cohort of people who’ve chosen to take care of sicker kids turns out to be really galvanized by the idea of parsimonious care, but it’s true.   In my case, it was the specific overutilization of ineffective therapies for bronchiolitis that started me down this road, but bronchiolitis is hardly the only place where we engage in waste in the hospital.  I was young and foolish once and I thought that if we just made everyone aware of the evidence in a timely fashion, then we’d make short work of the problem of overuse.  I’m no longer quite so naïve, and overuse turns out to be a deeply embedded and complicated problem.  So it’s gratifying for me to see the amount of attention that this topic has gotten lately.

A good place to start, in the event that you haven’t joined the “don’t just do something, stand there” club yet, is with a review by Korenstein published this January in Archives of Internal Medicine.  In that review, I learned that overuse is not particularly overstudied.  Korenstein notes that it’s an inherently difficult thing to study, since overuse is generally quite complicated to define and we don’t have a surplus of concerted efforts to do so in the US.  In fact, the authors point out that only 3 of the 49 HEDIS measures concern overuse. They also point out that underuse has been a much more popular topic for quality improvement research. It’s likely that this fact is related to what Pat Croskerry has termed Commission Bias, or our natural preference toward diagnostic or therapeutic action.  However, and Korenstein makes no mention of this, I’ve often wondered about the impact of funding sources for this type of research (exactly what industry would fund this type of investigation?).  With few funders and with an innate psychological bias toward an interventionist stance, it’s no wonder the article’s subtitle was “an understudied problem.”

But onward to what Korenstein's group found.  Well, the single most addressed topic in the literature was overuse of antibiotics for upper respiratory infection and the second most studied was coronary angiography and all things related to interventional cardiology. I thought for a while about what those two seemingly diverse topics might have in common; i.e. why did those particular topics get studied more extensively despite the many barriers to addressing overuse?  Personally I think that they both represent the kind of thing that just drives people crazy; they produce righteous indignation.  They represent high volume conditions (URI and chest pain) and there is an underlying economic predisposition toward doing the wrong thing, a perfect setup for righteous indignation.   Because who else but the true believer is going to hassle with this kind of research? 

And lest you think I’m poking fun, let’s turn to the one pediatric-specific condition that garnered enough overuse research to make it into the Korenstein review. Yep, you guessed it, bronchiolitis.  The four studies cited are the Cincinnati studies reporting the impact of protocolized care on multiple levels of utilization in bronchiolitis (Kotagal, Meuthing and Perlstein x2).  Interestingly, only one of these four studies has the word overuse in their title; and none of the five similar studies that exist addressing the impact of bronchiolitis guidelines at other institutions uses the term. The closest we get is “resource utilization.” They’ve all successfully decreased diverse measures of utilization in routine bronchiolitis care, mostly through the use of protocols. Most of these studies were published before the AAP put out their guideline, and most did not explicitly define what they were doing as tackling overuse. Rather, we are left to assume it’s overuse if the intervention was able to decrease use of the therapy or test without altering patient outcomes (sometimes actually improving them, btw). We talk around the topic, sometimes we call it overutilization instead of overuse (because the longer the word, the less offensive?) I like to think of it as allusive research on the elusive topic of waste.

I’ve personally done this kind of work - protocolizing bronchiolitis care, both on the ground locally at two very different institutions and promoting it in a large collaborative made up of multiple institutions.  And, I continue to marvel that there is no mechanism for a national push to make this approach standard. Bronchiolitis is the bane of our existence as inpatient pediatricians, our most common diagnosis for which waste is rampant and the solution is readily available. So, yes, consider me one of the true believers.  And yet, I still don’t routinely use the word waste.  In fact, I recently got feedback on a paper I’d written for which I’d chosen the somewhat unfortunate and obtuse title:  “Reducing Unnecessary Utilization in Bronchiolitis…”  An astute reviewer asked, “Doesn’t unnecessary utilization equal waste?”  And, all I could think was – yes, yes it does.

Korenstein D, Falk R, Howell EA, Bishop T, Keyhani S. Overuse of healthcare services in the United States: an understudied problem. Arch Intern Med.  2012;172(2):171-178.