Table 2 Societal, clinician, and patient-level considerations affecting overuse of health services (table adapted from Ellen et al.) [21]
From: Addressing overuse of health services in health systems: a critical interpretive synthesis
Level | Considerations | Explanation |
|---|---|---|
Societal | • Culture of ‘more is better’ | • The idea that ‘more is better’ permeates all aspects of society, including healthcare, which contributes to clinicians and patients to often opt for more tests or procedures, or take more drugs |
• Market forces | • Market forces that create increased demand for products and often exist without a counteracting force that makes the case for why more is not always better | |
Clinician | • ‘Better safe than sorry’ approach to care | • There is a prevailing culture of thoroughness and ‘better safe than sorry,’ which can mean ordering unnecessary tests ‘just to be sure’ |
• Acknowledgement of the issue and blame avoidance | • Some specialties have difficulty acknowledging that a service, test or procedure in which they have a vested interest may be overused • When provider groups have been asked to create lists of low-value services, they tend to include recommendations for other clinicians about what to do (or not to do) rather than address overuse by themselves and their colleagues | |
• Ability or willingness to change established ways of providing care | • As established in the behaviour-change literature, changing the way clinicians practice can be difficult and takes time | |
Patient | • Perception that clinicians that do more are better | • Receiving a test or treatment, even if it does not offer measurable benefits, is often seen as needed as the logical end point of an interaction between a patient and clinician |
• Demand for tests (e.g. from ‘well-informed’ patients) that are not evidence based | • Patients may not believe that their particular service, test or procedure is of low value and, when they are ill, disregard efforts to address overuse that are ‘for the greater good’ • While the information presented by patients to their clinician may be accurate, they may not be fully informed about what they need and hence many demand too many services and/or services that are inappropriate | |
• Citizen/patient health literacy | • Limited health literacy is a barrier to understanding health information and necessary alternatives, which can lead to the overuse of health services such as emergency room visits and hospitalisations | |
• Patients are not always consulted in decision-making processes | • Patients are often not engaged, or are engaged too late in the process and, as a result, do not fully understand, appreciate or agree with the decisions being proposed by their provider |