The RAND’s definition of appropriateness is the most widely used: “for an average group of patients presenting to an average US physician…the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the procedure is worth doing…excluding considerations of monetary cost”.2 Appropriateness requires input from various levels of healthcare experts and can have many clinical, economic, social, legal, and ethical considerations that must be evaluated. It is extremely important to consider who is making the judgment, the level of evidence that is being incorporated, and the process that is used in development to incorporate input.
From an economic perspective, appropriateness and the quality of care can be identified in three forms: overuse, underuse and misuse.3
- Overuse occurs when a service is provided even though its risk of harm exceeds its likely benefit, with the caveat of when it is clinically necessary. Economically, this also occurs when the cost of care exceeds the added benefit of care.
- Underuse is when a service is not provided even though it would be medically beneficial to the patient. Historically, this has been a pattern with Medicare enrollees.
- Misuse happens with medical errors that result in complications including things like an incorrect diagnosis, infections during a hospital stay, etc. Misuse can often result in harm to the patient that is preventable.
Overuse of unnecessary care is most prominent in high-income nations. It is estimated that between 10-30% of all healthcare practices have little to no benefit to the patient.4 Among Medicare beneficiaries, 41% receive low-value care making up for 2.6% of overall annual spending.5 A recent study by Dr. Michael L. Barnett, Harvard School of Public Health, found that overuse was equally common for patients with Medicaid or patients that are uninsured compared to patients with private insurers.6
Today, only 32% of ACOs reported they have implemented strategies to reduce low-value care services.7 Studies have shown positive association between health systems without a teaching hospital and higher use of low value care.8 ACOs can take the learnings from these academic institutions’ success and incorporate their strategies into their own programs.
For decades, an annual mammogram was recommended for all women, regardless of breast cancer risk, from age 40 until death. The USPSTF, ACP, & ACS recommend against this blanket approach. While popular, these groups found that this practice was unneeded for this entire population. For example, for the elderly population who may have multiple comorbidities, a screening would not be beneficial. More importantly, an abundance of evidence showed screenings in inappropriate populations led to more patient harm than good. It is estimated that 85% of physicians follow this outdated practice. Is healthcare appropriate when the harm outweighs the benefit?
Underuse occurs when a service is not provided (or accessible) to a patient even though it would be medically beneficial. Oftentimes, cost to a patient can be a barrier to appropriate use of care, and is an area that a physician wouldn’t always have control over in terms of adherence. A clinical trial found that enhancing prescription coverage increased compliance for medication adherence post myocardial infarction. In turn, this decreased rates of first major vascular events. This not only lowered patient spending but overall costs on the healthcare system.9
In addition to economic barriers, access to care can also lead to the underutilization of necessary medical intervention, particularly for rural populations. Studies have shown that population health in rural areas (as compared to urban) is inferior due to constraints around transportation, physician supply and retention, as well as scarcity of services offered.10 These obstacles perpetuate the underuse of basic and essential care, such as routine immunizations or cancer screenings.
Colorectal cancer (CRC) is the third most common cancer in the world. In the United States, approximately 151,030 diagnoses are made annually. Colorectal cancer can be fatal, unless it is caught early. Colon cancer screening rates have been slowly and steadily increasing over the past decade while incidence has decreased overall (apx. 1% per year). However, the incidence rate of early onset CRC (ages 40-50) is on the rise at 2% per year from 1995 to 2016. This rise has disproportionately affected black Americans.11
In 2018, the American Cancer Society was one of the first organizations to recognize the underuse of colon cancer screenings in this population and changed their guideline to screen patients at age 45 instead of 50.12 Many medical organizations soon followed this trend due to the abundance of scientific evidence. Lowering the screening age makes CRC screenings more accessible to patients, allows physicians to catch and treat cancer sooner, and improves health outcomes for a system.