Comment
harmful care. The authors argue that these drivers fall to recognise the opportunity to eliminate poor care and
into three important categories: money, finance, and
organisations; knowledge, beliefs, assumptions, bias,
and uncertainty; and power and human relationships.
To begin to address each of these levels, the roles of all
Jenny Matthews/Panos
actors have to be examined closely: patients, community
leaders, and civil society; health-care providers and
health service organisations; national policy makers
and health technology assessment institutions; and
global health leaders and professional societies. The best
example, where progress is slowly being made, is perhaps
that of reduced antibiotic prescribing to combat antibiotic
resistance.11 Patients and the public need to be protected
from false information for private gain and actively
educated, engaged, and empowered to be able to make
and accept decisions that are right for them. Clinicians and
health-service providers need to examine their knowledge
continuously and honestly, taking account of their biases
and motives for decision making. Atul Gawande, writing
for The New Yorker,12 admits that “as a doctor I am far more
concerned about doing too little than doing too much”,
and explains how the missed diagnoses and omitted
treatments haunt him far more than having caused harm
by too much treatment. And doctors and other health-care
workers need the right amount of time for each patient to
decide what the right care is. Our time-starved, factory-like
approach to primary care provision is not conducive to
delivering the right care with deleterious and more costly
consequences further down the line in a patient’s journey
through the health and social care system. National policy
makers, regulators, and health technology assessment
organisations need to work together to negotiate
affordable drug prices, and to publicly fund effective health
care and interventions. It is unbelievable that the UK still
funds homeopathy, on the one hand,13 and has failed to
recognise the outrageously inflated price for phenytoin
sodium capsules for patients with epilepsy, on the other.14
Professional societies need to work together at a global
level to provide strong, unbiased, evidence-based, and
relevant treatment guidelines. Global health leaders need
Avoiding overuse—the next quality frontier
Published Online As nations move toward universal health coverage
January 8, 2017
http://dx.doi.org/10.1016/
(UHC), the stakes on quality of care rise. The poorest
S0140-6736(16)32570-3 people in the world can least afford poor quality health
102 www.thelancet.com Vol 390 July 8, 2017
provide right care as the answer to truly and sustainably
achieve healthy lives and wellbeing for all.
This Series could form the basis for serious discussions
about what kind of health system we want for the
21st century as part of our commitment to universal
health coverage.
Sabine Kleinert, Richard Horton
The Lancet, London EC2Y 5AS, UK
We declare no competing interests.
1 UN. Sustainable Development Goals. 2015.
https://sustainabledevelopment.un.org/sdgs (accessed Dec 11, 2016).
2 Office for National Statistics. Health and life expectancies. 2016.
https://www.ons.gov.uk/peoplepopulationandcommunity/
healthandsocialcare/healthandlifeexpectancies#publications (accessed
Dec 11, 2016).
3 Xu J, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015.
Centers for Disease Control and Prevention. NCHS Data Brief, no 267,
December 2016. http://www.cdc.gov/nchs/data/databriefs/db267.pdf
(accessed Dec 11, 2016).
4 OECD. Health at a glance: Europe 2016. State of health in the EU Cycle. 2016.
http://www.oecd.org/health/health-at-a-glance-europe-23056088.htm
(accessed Dec 11, 2016).
5 Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical
services around the world. Lancet 2017; published online Jan 8. http://dx.
doi.org/10.1016/S0140-6736(16)32585-5.
6 Glasziou P, Straus S, Brownlee S, et al. Evidence for underuse of effective
medical services around the world. Lancet 2017; published
online Jan 8. http://dx.doi.org/10.1016/S0140-6736(16)30946-1.
7 Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care.
Lancet 2017; published online Jan 8. http://dx.doi.org/10.1016/S0140-
6736(16)30947-3.
8 Elshaug AG, Rosenthal MB, Lavis JN, et al. Levers for addressing medical
underuse and overuse: achieving high-value health care. Lancet 2017;
published online Jan 8. http://dx.doi.org/10.1016/S0140-6736(16)32586-7.
9 Saini V, Brownlee S, Elshaug AG, Glasziou P, Heath I. Addressing overuse and
underuse around the world. Lancet 2017; published online Jan 8. http://dx.doi.
org/10.1016/S0140-6736(16)32573-9.
10 Berwick DM. Avoiding overuse—the next quality frontier. Lancet 2017;
published online Jan 8. http://dx.doi.org/10.1016/S0140-6736(16)32570-3.
11 Goff DA, Kullar, R, Goldstein EJC, et al. A global call from five countries to
collaborate in antibiotic stewardship: united we succeed, divided we might
fail. Lancet Infect Dis 2016; published online Nov 17. http://dx.doi.
org/10/1016/S1473-3099(16)30386-3.
12 Gawande A. Overkill. The New Yorker, May 11, 2015. http://www.neworker.
com/magazine/2015/05/11/overkill-atul-gawande (accessed Dec 5, 2016).
13 Fenton S. NHS has spent more than £1·75m on homeopathy, despite
admitting there is “no good-quality evidence it works”. Independent,
Aug 7, 2016. http://www.independent.co.uk/life-style/health-and-families/
health-news/nhs-spending-funding-homeopathy-homeopathic-treatment-
evidence-a7177551.html (accessed Dec 11, 2016).
14 UK Government Competition and Markets Authority. CMA fines Pfizer and
Flynn £90 million for drug price hike to NHS. Dec 7, 2016. https://www.gov.
uk/government/news/cma-fines-pfizer-and-flynn-90-million-for-drug-price-
hike-to-nhs (accessed Dec 11, 2016).
care. They do not have the resources to repair the
damage when care goes wrong, their development
requires a healthy workforce, and money wasted

on ineffective or harmful care is money denied to
other essential services. Poor quality care damages
wealthy nations, too. Few high-income countries have
the political will to increase tax rates, and therefore
government investments reflect zero sum choices—
what public health care gets, public schools and public
housing lose. Private sector employers, the source of
half the health-care spending in the USA,1 also must
trade those costs off against worker incomes, capital
investments, and profit margins.
Quality refers to the degree of match between health
products and services, on the one hand, and the needs
they are intended to meet, on the other. Health care
that meets needs is high quality; health care that does
not meet needs is low quality. Four papers in a Series
in The Lancet focus on two important types of quality
defect: overuse of ineffective care and underuse of
effective care.2–5 With comprehensive reviews of the
available evidence, the Series authors leave little doubt
that reducing both overuse and underuse must take
centre stage in evolving health-care policies.
The magnitude of overuse reported by
Shannon Brownlee and colleagues2 may surprise many
readers. For example, a study in China found that 57% of
patients received inappropriate antibiotics; inappropriate
hysterectomies in the USA range from 16% to 70%;
inappropriate total knee replacement rates were 26%
in Spain and 34% in the USA. WHO has estimated that
6·2 million excess caesarean sections are performed each
year—50% of them are in Brazil and China.6 Underuse
of effective practices, especially in low-income settings,
is less surprising, although its magnitude is harder to
estimate. The variation is large across clinical procedures,
but, overall, in both low-income and high-income
nations, ineffective, scientifically unwarranted care seems
to account for close to about one-quarter to one-third of
total volume for many procedures, and for some specific
conditions and procedures, probably quite a bit more.
The problems of overuse and underuse highlighted
in this Lancet Series call to mind an unexpected finding
published nearly 30 years ago by the RAND Corporation:
that there was no correlation between geographical
variation in appropriateness of care and geographical
variation in the volume of care.7 Within the USA, regions
with low use of care had the same levels of inappropriate
care as regions with high use of care. The same finding
seems true today on a global scale.3
www.thelancet.com Vol 390 July 8, 2017 103
Comment
No one knows whether, in a perfect world, eliminating See Series pages 156, 169, 178,
and 191
all underuse and overuse would produce net savings
or increase total health-care costs. In richer nations,
especially the USA, the result would almost certainly be
reduced costs; in poorer ones, probably not. But, rich or
poor, no country can avoid the conclusion that overuse
drains opportunities from finite health resources—what
Nobel Prize winning political economist Eleanor Ostrom
called “common pool resources”.8 For nations with tight
constraints on investments in health, reducing overuse
could offer the biggest opportunity for releasing resources
to address underuse.
The social, economic, political, and psychological
factors that drive overuse are many, as highlighted by
Vikas Saini and colleagues.4 The authors classify these
drivers into three clusters: (a) the flow of money and
consequent effects on incentives and the integration of
care; (b) gaps in knowledge, misleading psychological
tendencies, and erroneous beliefs; and (c) asymmetries
in power between patients and providers, impeding
proper consideration of patients’ aims and preferences.
These influences are highly interrelated. For example,
the medical–industrial complex, aiming to increase
revenues and profit, feeds public expectations that more
care is always better care (even though it is not), funds
the incomes and education of health-care professionals
(shaping their incentives and beliefs), and controls much
of the research funding that purports to evaluate their
drugs and technologies (courting bias). The asymmetry
of power and information between doctors and patients
can push both toward interventionist care, even if fully
informed patients would prefer less invasive options.9,10
Fee-for-service health-care payment systems and those
that link hospital or physician incomes to volume, such
as percentage mark-ups for medication prescribing,
encourage excess and discourage scepticism about time-
honoured practices, even those of little merit.
With dynamics like these at work, addressing overuse
as a serious quality problem is not for the faint of heart.
If governments or scientific bodies attempt to prescribe,
through policy or payment, when a medical practice is
appropriate and when not, many status quo interests are
likely to respond with accusations of so-called rationing,
paralytic debates about the clinical evidence, defence of
the prerogatives of professionals, and even bribes.
Nonetheless, with the magnitude of waste so high,
and the risks to patients from ineffective care so grave,
 Comment
wavebreakmediamicro/123RF Stock Photo
it behoves health-care leaders worldwide to name the
problem of overuse clearly, and to support changes
in payment, training, and, when needed, regulation
to reduce it. The aim, in the words of quality expert
James Reinertsen, ought to be, “all the care, and only
the care, that will help the patient” (Reinertsen J, The
Reinertsen Group, personal communication). Building
the research base for distinguishing helpful from wasteful
care needs to be part of that plan.
In recent years, WHO and other national and
multinational bodies have courageously led moves
toward global improvement on two important
quality-of-care aims: to increase patient safety and to
reduce inappropriate use of antimicrobial agents.11 As
UHC gains traction, they should add a third quality aim to
that portfolio: reducing the overuse of ineffective care.
There would be an understandable tendency to try to
balance an assault on overuse with a simultaneous assault
on underuse. That would reassure some who would fear loss
of momentum toward encouraging increased investment
in health, especially in low-income nations. Even in the
poorest settings, however, it is important to attack overuse
as well as underuse, so that the resources recovered from
the former can be reinvested in reducing the latter.
For starters, WHO should designate a range of clinical
practices for which strong evidence already exists of
widespread overuse. WHO and others should organise
multinational learning networks for reducing overuse,
modelled on current quality improvement collaboratives.12
Multinational donors, organisations, and governments
should mount a several-year effort to improve the
104 www.thelancet.com Vol 390 July 8, 2017
empirical base for estimates of overuse, and to expand the
target list of types and patterns of overused care.
It would be helpful for researchers and policy analysts
to develop evidence-based international guidelines for
health-care payment, policy, and incentive structures that
could discourage overuse, to the advantage of patients
and communities. A best practice template for policy and
payment to support appropriateness should be developed
for the consideration of ministries and legislatures.
This landmark Lancet Series on overuse and underuse
constitutes a call-to-arms to improve health care globally
by better matching care to needs, and practice to science.
Reducing unwarranted, useless, and, therefore, harmful
care is an important part of that agenda.
Donald M Berwick
Institute for Healthcare Improvement, Cambridge, MA 02138, USA
donberwick@gmail.com
I declare no competing interests.
1 Kaiser Family Foundation. Health insurance coverage of the total population.
2015. http://kff.org/other/state-indicator/total-population/?currentTimefra
me=0&selectedRows=%7B%22wrapups%22:%7B%22united-
states%22:%7B%7D%7D%7D (accessed Dec 9, 2016).
2 Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical
services around the world. Lancet 2017; published online Jan 8. http://dx.
doi.org/10.1016/S0140-6736(16)32585-5.
3 Glasziou P, Straus S, Brownlee S, et al. Evidence for underuse of effective
medical services around the world. Lancet 2017; published online Jan 8.
http://dx.doi.org/10.1016/S0140-6736(16)30946-1.
4 Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care.
Lancet 2017; published online Jan 8. http://dx.doi.org/10.1016/S0140-
6736(16)30947-3.
5 Elshaug AG, Rosenthal MB, Lavis JN, et al. Levers for addressing medical
underuse and overuse: achieving high-value health care. Lancet 2017;
published online Jan 8. http://dx.doi.org/10.1016/S0140-6736(16)32586-7.
6 Gibbons L, Belizán JM, Lauer JA, et al. The global numbers and costs of
additionally needed and unnecessary Caesarean sections performed per
year: overuse as a barrier to universal coverage. World Health Report (2010),
Background Paper, No.30. Geneva: World Health Organization, 2010.
7 Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain
geographic variation in the use of health care services? JAMA 1987;
258: 2533–37.
8 Ostrom E. Governing the commons: the evolution of institutions for
collective action. Cambridge, UK: Cambridge University Press, 1990.
9 Stacy D, Légaré F, Col NF, et al. Decision aids for people facing health
treatment or screening decisions. Cochrane Database Syst Rev 2014;
1: CD001431.
10 Pittet D, Donaldson L. Clean care is safer care: the first global challenge of
the WHO World Alliance for Patient Safety. Infect Control Hosp Epidemiol
2005; 26: 891–94.
11 World Bank Group. Drug resistant infections: a threat to our economic
future. Washington, DC: International Bank for Reconstruction and
Development, The World Bank, 2016.
12 Barker PM, Reid A, Schall MW. A framework for scaling up health
interventions: lessons from large-scale improvement initiatives in Africa.
Implement Sci 2016; 11: 12.