A practical framework for understanding and reducing medical overuse: Conceptualizing overuse through the patient-clinician interaction

The final framework is shown in the Figure. Within the healthcare system, patients are influenced by the culture of healthcare consumption, which varies within and among countries.²⁷ Clinicians are influenced by the culture of medical care, which varies by practice setting,²⁸ and by their training environment.²⁹ Both clinicians and patients are influenced by the practice environment and by personal experiences. Ultimately, clinical decisions occur within the specific patient–clinician interaction.²⁴ Table 1 lists each domain’s components, likely impact on overuse, and estimated strength of supporting evidence. Interventions can be conceptualized within appropriate domains or through the interaction between patient and clinician.

We developed a novel and practical conceptual framework for characterizing drivers of overuse and potential intervention points. To our knowledge, this is the first framework incorporating a patient-specific approach to overuse and emphasizing the patient–clinician interaction. Key strengths of framework development are inclusion of a range of perspectives and characterization of the evidence within each domain. Limitations include lack of a formal systematic review and broad, qualitative assessments of evidence strength. However, we believe this framework provides an important conceptual foundation for the study of overuse and interventions to reduce overuse.

Framework Applications

This framework, which highlights the many drivers of overuse, can facilitate understanding of overuse and help conceptualize change, prioritize research goals, and inform specific interventions. For policymakers, the framework can inform efforts to reduce overuse by emphasizing the need for complex interventions and by clarifying the likely impact of interventions targeting specific domains. Similarly, for clinicians and quality improvement professionals, the framework can ground root cause analyses of overuse-related problems and inform allocation of limited resources. Finally, the relatively weak evidence on the role of most acknowledged drivers of overuse suggests an important research agenda. Specifically, several pressing needs have been identified: defining relevant physician and patient cultural factors, investigating interventions to impact culture, defining practice environment features that optimize care appropriateness, and describing specific patient–clinician interaction practices that minimize overuse while providing needed care.

Targeting Interventions

Domains within the framework are influenced by different types of interventions, and different stakeholders may target different domains. For example:
 

• The culture of healthcare consumption may be influenced through public education (eg, Choosing Wisely^® patient resources)^30-32 and public health campaigns.
• The practice environment may be influenced by initiatives to align clinician incentives,³³ team care,³⁴ electronic health record interventions,³⁵ and improved access.³⁶
• Clinician attitudes and beliefs may be influenced by audit and feedback,^37-40 reflection,⁴¹ role modeling,⁴² and education.^43-45
• Patient attitudes and beliefs may be influenced by education, access to price and quality information, and increased engagement in care.^46,47
• For clinicians, the patient–clinician interaction can be improved through training in communication and shared decision-making,25 through access to information (eg, costs) that can be easily shared with patients,^48,49 and through novel visit structures (eg, scribes).⁵⁰
• On the patient side, this interaction can be optimized with improved access (eg, through telemedicine)^51,52 or with patient empowerment during hospitalization.
• The culture of medicine is difficult to influence. Change likely will occur through:

○ Regulatory interventions (eg, Transforming Clinical Practice Initiative of Center for Medicare & Medicaid Innovation).

○ Educational initiatives (eg, high-value care curricula of Alliance for Academic Internal Medicine/American College of Physicians⁵³).

○ Medical journal features (eg, “Less Is More” in JAMA Internal Medicine⁵⁴ and “Things We Do for No Reason” in Journal of Hospital Medicine).

○ Professional organizations (eg, Choosing Wisely^®).

As organizations implement quality improvement initiatives to reduce overuse of services, the framework can be used to target interventions to relevant domains. For example, a hospital leader who wants to reduce opioid prescribing may use the framework to identify the factors that encourage prescribing in each domain—poor understanding of pain treatment (a clinician factor), desire for early discharge encouraging overly aggressive pain management (an environmental factor), patient demand for opioids combined with poor understanding of harms (patient factors), and poor communication regarding pain (a patient–clinician interaction factor). Although not all relevant factors can be addressed, their classification by domain facilitates intervention, in this case perhaps leading to a focus on clinician and patient education on opioids and development of a practical communication tool that targets 3 domains. Table 2 lists ways in which the framework informs approaches to this and other overused services in the hospital setting. Note that some drivers can be acknowledged without identifying targeted interventions.

Moving Forward

Through a multi-stakeholder iterative process, we developed a practical framework for understanding medical overuse and interventions to reduce it. Centered on the patient–clinician interaction, this framework explains overuse as the product of medical and patient culture, the practice environment and incentives, and other clinician and patient factors. Ultimately, care is implemented during the patient–clinician interaction, though few interventions to reduce overuse have focused on that domain.