As health policy leaders search for reasons why U.S. healthcare costs continue to soar as compared with healthcare costs of other developed countries, the topic of medical-service overutilization has drawn fresh interest and attention in recent years.
Between 6% and 8% of all U.S. healthcare spending falls into the overuse category, based on conservative estimates, while studies of geographic variation have found the proportion of overuse Medicare spending is closer to 29%, according to a study in The Lancet.
Overuse, which can be defined as the provision of medical services for which the potential for harm exceeds the potential for benefit, often leads to excessive costs and reduces patient safety. Less understood is that the underutilization of medical services is also a very real problem that can similarly result in compromised patient care, higher long-term care costs, and the failure to achieve quality-performance goals.
To protect against underutilization, health systems and hospitals are increasingly turning to analytical tools that compare actual physician orders against databases of evidence-based interventions proven to drive better health outcomes.
An example of underutilization
The causes of underutilization are many and often vary by procedure. However, one common thread driving the trend is simply a lack of awareness. A substantial body of new medical research is published each month, reporting, for example, the latest evidence illustrating various treatments and procedures that could improve mortality and reduce hospital readmissions. Given the ongoing introduction of new data, it is not realistic to expect busy, practicing clinicians to have the capacity to stay current with all of the latest evidence-based findings.
Consider the example of cardiac rehabilitation, which has been shown to reduce hospitalizations and improve outcomes for certain patients who have undergone cardiac-related procedures. Despite the evidence, just 20% of eligible patients complete cardiac rehabilitation, according to the Agency for Healthcare Research and Quality (AHRQ).
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However, increasing cardiac rehabilitation participation from 20% today to 70% in the future could save almost 25,000 lives and prevent an estimated 180,000 hospitalizations annually. Cardiac rehabilitation encompasses three components that deliver several benefits to patients:
- Structured exercise to improve cardiovascular health, reduce risk factors and improve mood;
- Education to help patients manage their conditions and make lifestyle changes that enhance heart health; and
- Counseling to reduce stress and address psychosocial factors that impact health.
For patients, the advantages of cardiac rehabilitation include reduced risk of death and heart attack recurrence, better medication adherence, and enhanced quality of life. From the perspective of health systems, greater utilization of cardiac rehabilitation can lead to reduced readmissions, improved quality metrics, and increased readiness for value-based payment initiatives, according to AHRQ.
Much of the problem of underutilization of cardiac rehabilitation stems from low rates of referrals for these services. AHRQ attributes these low rates to gaps in physician awareness of who needs rehabilitation and the benefits of it, inconsistency in referral patterns, the absence of a system in hospitals that automatically refers eligible patients, and a lack of clinician knowledge about available local programs.
Adherence to standards of care
To help overcome gaps in physician knowledge, hospitals commonly deploy evidence-based order sets. A physician order set is a standardized set of evidence-based treatment guidelines for various conditions, such as heart failure or chronic obstructive pulmonary disorder. For a given condition, these standardized lists include recommended prescription drug options, diagnostics, lab tests, and follow-up care.
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Standardized, evidence-based order sets help clinicians improve the quality and safety of the patient care they deliver by prompting utilization of the most appropriate care. If, for example, clinical staff forget to refer a heart failure patient to a rehabilitation center prior to discharge, the order set would suggest that they complete a referral. The hospital can then avoid a situation in which patient care is compromised, which could result in a decline in the patient’s condition and possible rehospitalization.
When standardized order sets are in place, hospitals can also leverage analytics tools to assess the level of physician compliance with evidence-based standards. These analyses can then provide the basis for ongoing education or institution-wide campaigns that impress upon the clinicians the importance of following evidence-based practices.
Although it receives little attention, underutilization of appropriate care has the potential to lead to less favorable patient outcomes that may result in financial penalties for health systems and avoidable complications, including hospital readmissions or even death. By embracing evidence-based standards and monitoring the adherence to appropriate care, hospitals can optimize clinical outcomes, while also supporting the organization’s financial objectives.
Robert Kass, M.D., is a managing editor at Zynx Health.