Overuse and Systems of Care: a Systematic Review

Background: Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.

Objective: To compare rates of overuse in different health care systems and examine whether certain systems of care or insurers have lower rates of overuse of health care services.

Data Sources: Articles published in MEDLINE between 1978, the year of publication of the first framework to measure quality, and June 21, 2012.

Study Selection: Included studies compared rates of overuse of procedures, diagnostic tests, or medications in at least 2 systems of care.

Data Extraction: Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data.

Results: We identified 7 studies which compared rates of overuse of 5 services across multiple different health care settings. National rates of inappropriate coronary angiography were similar in Medicare HMOs and Medicare FFS (13% vs. 13%, P=0.33) and in a state-based study comparing 15 hospitals in New York and 4 hospitals in a Massachusetts-managed care plan (4% vs. 6%, P>0.1). Rates of carotid endarterectomy in New York State were similar in Medicare HMOs and Medicare FFS plans (8.4% vs. 8.6%, P=0.55) but nonrecommended use of antibiotics for the treatment of upper respiratory infection was higher in a managed care organization than a FFS private plan (31% vs. 21%, P=0.02). Rates of inappropriate myocardial perfusion imaging were similar in VA and private settings (22% vs. 16.6%, P=0.24), but rates of inappropriate surveillance endoscopy in the management of gastric ulcers were higher in the VA compared with private settings (37.4% vs. 20.4%-23.3%, P<0.0001).

Conclusions: The available evidence is limited but there is no consistent evidence that any 1 system of care has been more effective at minimizing the overuse of health care services. More research is necessary to inform current health care reform efforts directed at reducing overuse.