A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient‐Clinician Interaction

Abstract

The overuse of medical services is an increasingly recognized driver of poor quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. Other drivers of utilization influence this interaction and include health care system factors, the practice environment, the culture of professional medicine, the culture of health care consumption, and individual patient and clinician factors. The variable strength of evidence in support of these domains highlights important areas for further investigation.

Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity

“…Rather, students appear to be influenced by many of the same drivers of wasteful behaviors reported by residents and practicing physicians such as saving time, satisfying curiosity, appeasing patients, and protecting the healthcare team from liability (so-called defensive medicine). [32][33][34][35][36][37][38][39][40] Other drivers of wasteful behaviors may be unique to trainees such as suggesting a test solely to anticipate what a supervisor would want, show off one's ability to generate a broad *Percentage calculations are not all based on a denominator of 1304 because of missing responses to some survey items; percentages may not add up to 100% due to rounding; students were asked how many times during the current academic year they had performed each behavior differential diagnosis, or build clinical experience. Students are keenly aware of the impact of clerkship evaluations on the likelihood of matching into desired residency programs and may thus engage in these types of low-value behaviors to create an impression of competence or otherwise ingratiate themselves to their supervisors.…”

Peer‐pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals

“…Between physicians/healthcare‐institutions, practice variations are widely recognised as a marker of potential overuse/overtreatment …”

“…Between physicians/healthcare-institutions, practice variations are widely recognised as a marker of potential overuse/overtreatment. 20 Even if numerous studies targeted to waste in healthcare have been published in recent years, [11][12][13] interventions aiming at reducing variation in treatments and diagnostic procedures, are lacking. 21 One of the reasons is that an intervention can be promoted at the service or hospital level following the temporal trend of the targeted prescription behaviour; while investigating the impact on variation implies to act at the network level analysing and benchmarking before and after data.…”

Study Protocol for Draup: De-implementation Ofroutine Chest Radiographs After Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol, A Hybrid Implementation/effectiveness Study

“…We will design a multifaceted strategy bundle guided by Morgan's framework for medical overuse and will tailor the strategies to any additional determinants identi ed in Aim 1. [28] This framework also allows prioritization of speci c interventions toward understanding medical overuse and deimplementation ( Fig. 2).…”

“…We will identify a multifaceted strategy bundle (that targets both implementation and deimplementation) that we believe to be feasible, adaptable, generalizable, and informed by our focus group barriers and Morgan's framework for medical overuse. [28] (Table 1) These strategies will address the possible domains/drivers of in uence for understanding medical overuse: Audit & Feedback, Algorithm development, Planned Adaptation, Organizational Support, Decision Support, Education & Training. Details of our strategy bundle are described in Table 2.…”