Overuse and systems of care: a systematic review

Current health care reform efforts are focused on reorganizing health care systems to reduce waste in the US health care system.


To compare rates of overuse in different health care systems and examine whether certain systems of care or insurers have lower rates of overuse of health care services.


Articles published in MEDLINE between 1978, the year of publication of the first framework to measure quality, and June 21, 2012.


Included studies compared rates of overuse of procedures, diagnostic tests, or medications in at least 2 systems of care.


Four reviewers screened titles; 2 reviewers screened abstracts and full articles and extracted data.


We identified 7 studies which compared rates of overuse of 5 services across multiple different health care settings. National rates of inappropriate coronary angiography were similar in Medicare HMOs and Medicare FFS (13% vs. 13%, P=0.33) and in a state-based study comparing 15 hospitals in New York and 4 hospitals in a Massachusetts-managed care plan (4% vs. 6%, P>0.1). Rates of carotid endarterectomy in New York State were similar in Medicare HMOs and Medicare FFS plans (8.4% vs. 8.6%, P=0.55) but nonrecommended use of antibiotics for the treatment of upper respiratory infection was higher in a managed care organization than a FFS private plan (31% vs. 21%, P=0.02). Rates of inappropriate myocardial perfusion imaging were similar in VA and private settings (22% vs. 16.6%, P=0.24), but rates of inappropriate surveillance endoscopy in the management of gastric ulcers were higher in the VA compared with private settings (37.4% vs. 20.4%-23.3%, P<0.0001).


The available evidence is limited but there is no consistent evidence that any 1 system of care has been more effective at minimizing the overuse of health care services. More research is necessary to inform current health care reform efforts directed at reducing overuse.




Keyhani S
Falk R
Howell EA
Bishop T
Korenstein D