We have all seen the Choosing Wisely lists and the new “Things We Do for No Reason” section in the Journal of Hospital Medicine. We have heard a lot about common areas of overuse in hospitals. Sure, there have been some success stories of hospitalists leading projects to decrease an area of overuse, but when you get down to it, have we really done much to not just recognize overuse but to actually decrease it?
Think about the patient safety movement over the last two decades. Telling horrifying stories of wrong-limb surgeries may have caught headlines, but that did not do much to stop the problem from still happening. The medical world had to shift our thinking from one of individual blame to recognizing the role of systems and environments in creating these problems. We had to put structures in place, such as safety review committees and mandated processes for responding to defined “never events.” By creating reporting structures and uncovering problems, hospital administrators had to pay attention and commit resources to address them. Yes, I know – we still have much to do to improve safety within hospitals, but it seems clear that patient safety has improved over time.
If we are going to make real progress on addressing overuse, then maybe we need to put similar structures of accountability in place. To this point, my colleagues at UCSF and I just published an article in JAMA as part of their new professionalism series arguing that resource overutilization should be considered an adverse event. (If you prefer to listen rather than read, there is a fantastic associated podcast featuring a discussion between Dr. Andy Lai and JAMA editor Dr. Ed Livingston digging into these issues)
The original idea was not really ours, but instead sort of fell in our lap. Dr. Lai leads the hospital medicine patient safety case review committee at UCSF, and one day he received an unusual referral. A primary care physician contacted him about a primary care patient of hers who had been recently admitted and treated for acute cholecystitis. This patient had been successfully treated, recovered, and had been safely discharged back home, without any obvious adverse events. So what could possibly be the problem? The primary care physician requested this case be reviewed because she was concerned that her patient had received too much testing during her recent hospital stay.
So, should excessive resource utilization be considered an adverse event and be reviewed in case review committees?
As mentioned in the JAMA article, the benefits of this approach seem to be that if overuse is considered equal to adverse events, then “health care systems will be signaling the importance of addressing this insidious problem and will take the initial steps to foster a culture and training environment that supports high-value care.”
But, of course there are also potential downsides and many unanswered questions.
If overtesting is an adverse event in the setting of NO harm, but potential harm (e.g., incentalomas, false positive test results, radiation), then where do we draw the line? Do we only consider high-ticket items and/or testing that present greater theoretical risks, like CT scans with contrast?
In addition, case review committees and hospital administration only have so much time and resources, so could including these types of cases detract from the focus on events that have caused the most serious physical harms to patients?
A related editorial asks many of these questions and advises we “should not imply that all overuse be viewed as a threat to patient safety. While overuse has the potential for patient harm, in a practical sense, integrating overuse into the patient safety infrastructure only when overuse causes serious direct patient harm can reinforce its importance while retaining the integrity of the critical mission to protect patients.”
What do you think? Should overuse be integrated into patient safety? If so, at what level of the infrastructure?
Christopher Moriates, MD is a hospitalist, the assistant Dean for Healthcare Value and an Associate Professor of Internal Medicine at Dell Medical School at University of Texas, Austin. He is also Director of Implementation Initiatives at Costs of Care. He co-authored the book Understanding Value-Based Healthcare (McGraw-Hill, 2015), which Atul Gawande has called “a masterful primer for all clinicians,” and Bob Wachter said is “essential reading for everyone who care about making our system better.”