A new series launched by The Lancet, entitled the ‘”Right Care Series,” features major commentaries by Vikas Saini (Lown Institute, Boston), Adam Elshaug (University of Sydney), Paul Glasziou (Bond University), Don Berwick (Institute for Healthcare Improvement, Cambridge, MA) and others who examine the areas and extent of overuse and underuse of health and medical services.
The series defines overuse as “the provision of medical services that are more likely to cause harm than good,” and underuse as “the failure to use effective and affordable medical interventions”.
The authors reveal that both overuse and underuse are extensive problems but happen side-by-side in different countries, within countries, among populations, within institutions, and even for a single person.
“This situation offers an enormous, and currently poorly recognised, opportunity to tackle underuse and overuse together to achieve the right care for health and wellbeing, and a sustainable health care system,” says Glasziou.
Elshaug adds, “All countries including Australia are struggling with spiralling costs of health care, with increasing prospects of rationing and restricting services — which would increase inequality and worsen our health outcomes. It’s tempting to think that rich countries will have overuse problems and poor countries will have underuse problems, but it’s not that simple. In Australia, the U.S. and elsewhere, you actually see both problems — worthwhile, cost-effective interventions that are vastly underused, and high-cost effective services of little or no value that are commonplace.
Elshaug also points out the growing relevance of this issue within the Asia-Pacific region, as more developing economies through Asia strive for universal health care (UHC). He states: “ensuring that everyone within a society has equitable access to some agreed basic level of affordable, effective and wanted health care services is a moral imperative now formally recognized by the United Nations. However, as we state in our Series of papers, the journey to UHC will — and ought to — focus more of the world’s attention towards redressing low-value care as an urgent task. The fundamental ethical, economic, and political challenge arising from poor care is that as long as funds — including tax-payers funds via Medicare — are devoted to low-value care, the potential for health gain elsewhere in the system is unnecessarily restricted.”
“This landmark Lancet 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.” Berwick says. “Reducing unwarranted, useless, and, therefore, harmful care is an important part of that agenda.”
Key messages of the series are:
- Overuse and underuse coexist within populations, within systems, and even within patients around the world.
- Underuse of proven medical care and overuse of unproven services causes suffering to millions of people around the world. The costs are serious: physical, psychological, and social harms for patients and wasteful misallocation of resources for society
- Because most care falls in a grey zone in which benefits and harms are not clear, attention to preferences of patients is essential.
- Over and underuse are symptoms of a health-care system that does not reflect the ethics of medicine. They undermine the capacity of countries to achieve sustainable universal health coverage and to ensure that health care is a human right. Action is possible and necessary.