Comment
testing, whereas other cases might be satisfactorily
investigated with imaging techniques.
*Rick R van Rijn, Peter M Leth
Department of Radiology, Emma Children’s Hospital—Academic
Medical Center Amsterdam, Amsterdam, Netherlands (RRvR); and
Department of Forensic Medicine, University of Southern
Denmark, Odense, Denmark (PML)
r.r.vanrijn@amc.uva.nl
We declare no competing interests.
Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access
article under the CC BY 4.0 license.
1 Dutto O. Fotografi del sistema arterioso ottenute con raggi Röntgen.
Rendic Reale Acad Lincei 1896; 5: 129 (in Italian).
From universal health coverage to right care for health
Achieving universal health coverage is the most
important means to advance health and wellbeing during
the next decade. Too many countries—and not only in
low-income or middle-income settings—do not have a
health system that provides “access to quality essential
health-care services and access to safe, effective, quality
and affordable essential medicines and vaccines for all”,
as described in Sustainable Development Goal 3.8.1
Even many high-income countries, such as the USA
and the UK, see important inequalities in income, life
expectancy, and health outcomes,2,3 and the prevailing
political and economic landscapes are not encouraging
for a reversal of this trend in the foreseeable future. At the
same time, changing demographics in many countries
mean that the share of the population with two or more
chronic conditions will increase. As a result, the resilience
and sustainability of health systems will be put under even
more pressure. In a recent report by the Organisation for
Economic Co-operation and Development, it is estimated
that the proportion of the population in European Union
countries aged 65 years or older will increase from 20%
in 2015 to 30% by 2060.4 The same report states that in
2013, more than 1·2 million people in European Union
countries died from avoidable illnesses and injuries4—
people who would not have died had there been more
effective public health and prevention policies in place, or
more timely and effective health care. Yet all countries are
struggling with spiralling costs of health and social care,
with the prospect of rationing and restricting services—a
strategy that would increase inequality and injustice
www.thelancet.com Vol 390 July 8, 2017 101
2 Thali MJ, Yen K, Schweitzer W, et al. Virtopsy, a new imaging horizon in
forensic pathology: virtual autopsy by postmortem multislice computed
tomography (MSCT) and magnetic resonance imaging (MRI)—a feasibility
study. J Forensic Sci 2003; 48: 386–403.
3 Grabherr S, Grimm J, Dominguez A, Vanhaebost J, Mangin P. Advances in
post-mortem CT-angiography. Br J Radiol 2014; 87: 20130488.
4 Grabherr S, Grimm JM, Heinemann A. Atlas of postmortem angiography.
Cham: Springer International Publishing, 2016.
5 Grabherr S, Doenz F, Steger B, et al. Multi-phase post-mortem CT
angiography: development of a standardized protocol. Int J Legal Med 2011;
125: 791–802.
6 Rutty GN, Morgan B, Robinson C, et al. Diagnostic accuracy of
post-mortem CT with targeted coronary angiography versus autopsy for
coroner-requested post-mortem investigations: a prospective, masked,
comparison study. Lancet 2017; published online May 24. http://dx.doi.
org/10.1016/S0140-6736(17)30333-1.
7 Thayyil S, Sebire NJ, Chitty LS, et al. Post mortem magnetic resonance
imaging in the fetus, infant and child: a comparative study with
conventional autopsy (MaRIAS Protocol). BMC Pediatr 2011; 11: 120.
still further. Failure to provide treatment and preventive Published Online
January 8, 2017
care at all remains the unacceptable reality in many http://dx.doi.org/10.1016/
low-income and middle-income countries for most of S0140-6736(16)32588-0
their populations. Clearly, something has to change in our See Comment pages 102
and 105
thinking about the provision of health and health care to
See Series pages 156, 169, 178,
achieve health and wellbeing for all. and 191
In a Series of papers5–8 and Comments9,10 in The Lancet,
Vikas Saini and colleagues provide a framework for such
a change of thinking. The Right Care Series examines the
areas and extent of overuse and underuse of health and
medical services around the world. It defines overuse as
“the provision of medical services that are more likely to
cause harm than good”,5 and underuse as “the failure to
use effective and affordable medical interventions”.6 The
Series authors argue that both overuse and underuse
happen side-by-side in different countries, within
countries, among populations, within institutions,
and even for a single person. This situation offers an
enormous (and currently poorly recognised) opportunity
to tackle underuse and overuse together to achieve the
right care for health and wellbeing.
What is right care? In its simplest definition it is care
that weighs up benefits and harms, is patient-centred
(taking individual circumstances, values, and wishes into
account), and is informed by evidence, including cost-
effectiveness. The Series authors acknowledge that most
medical services fall into a grey zone where the benefit
and harm ratio for a given individual is unknown.
However, an important start is to think about, and
aim to influence, the drivers of poor, unnecessary, and
 Comment
harmful care. The authors argue that these drivers fall
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
to recognise the opportunity to eliminate poor care and
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.
 Series
Lancet 2017; 390: 156–68
Published Online
January 8, 2017
http://dx.doi.org/10.1016/
S0140-6736(16)32585-5
This online publication has been
corrected. The corrected version
first appeared at thelancet.com
on March 3, 2022
This is the first in a Series of
four papers about right care
See Comment pages 101, 102,
and 105
Lown Institute, Brookline, MA,
USA (S Brownlee MSc,
Prof A G Elshaug PhD,
V Saini MD); Department of
Health Policy, Harvard T.H. Chan
School of Public Health,
Cambridge, MA, USA
(S Brownlee); Institute for
Global Health Innovation,
Imperial College, London, UK
(K Chalkidou MD); Center for
Research in Evidence-Based
Practice, Bond University, Gold
Coast, QLD, Australia
(Prof J Doust PhD,
Prof P Glasziou FRACGP);
Menzies Centre for Health
Policy, School of Public Health,
Sydney Medical School, The
University of Sydney, Sydney,
NSW, Australia (Prof A G Elshaug,
K Chalmers BSc); Royal College of
General Practitioners, London,
UK (I Heath FRCGP); The World
Bank, Phnom Penh, Cambodia
(S Nagpal MD); LSE Health,
London School of Economics
and Political Science, London,
UK (D Srivastava PhD); and
Memorial Sloan Kettering
Cancer Center, New York, NY,
USA (D Korenstein MD)
*I Heath retired in January, 2010
Correspondence to:
Ms Shannon Brownlee, Lown
Institute, Brookline MA 02446,
USA
sbrownlee@lownistitute.org
156 www.thelancet.com Vol 390 July 8, 2017
Right care 1
Evidence for overuse of medical services around the world
Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou, Iona Heath*, Somil Nagpal, Vikas Saini, Divya Srivastava,
Kelsey Chalmers, Deborah Korenstein
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a
pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is
challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse
can also be measured indirectly through examination of unwarranted geographical variations in prevalence of
procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income
countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded
services can harm patients physically and psychologically, and can harm health systems by wasting resources and
deflecting investments in both public health and social spending, which is known to contribute to health. Although
harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be
increasing worldwide.
Introduction drawn on five systematic reviews (one unpublished)4,10–12 of
Overuse, which Chassin and Galvin defined as ‘the overuse to help inform this paper, supplemented with
provision of medical services for which the potential for reference tracking and additional structured searches of
harm exceeds the potential for benefit’,1 is increasingly scientific and grey literature. Subsequent papers in this
recognised around the world. Directly measuring overuse Series13–15 examine the underuse of medical services
requires a definition of appropriate care, which is often worldwide, the causes of overuse and underuse, and
challenging. In the USA, estimates of spending on overuse potential solutions for both.
vary widely: conservative estimates based on the direct
measurement of individual services range from 6% to 8% What is overuse?
of total health-care spending,2 whereas studies of “Though the doctors treated him, let his blood, and gave
geographical variation (an indirect measure) indicate that him medications to drink, he nevertheless recovered.”
the proportion of Medicare spending on overuse is closer to
Leo Tolstoy, War and Peace
29%.3 Worldwide, overuse of individual services can be as
high as 89% in certain populations.4 Although overuse has Although Chassin and Galvin’s definition of overuse is
mainly been documented in high-income countries succinct, and may have broad intuitive appeal, it is
(HICs), low- and middle-income countries (LMICs) are difficult to address. To directly measure overuse, a
not immune. Evidence suggests widespread overuse is definition for the appropriateness of a service is required,
occurring in countries as diverse as Australia,5 Brazil,6 based on evidence that considers the balance between
Iran,7 Israel,8 and Spain.9 Overuse can coexist with unmet benefits and harms for a population or individuals.
health-care needs, particularly in LMICs. However, quantifying benefits and harms is often
We aimed to highlight the significance of the problem of problematic, because evidence regarding benefits is
overuse and explore what is known regarding the scope often incomplete, and for many services harms are
and consequences of such, around the world. We have poorly documented.16 Furthermore, the threshold
between appropriate and inappropriate care can vary
among patients or patient groups. Additionally, the role
Key messages of cost in defining low-value services varies in different
• Overuse is difficult to measure and has not been well settings (panel).
characterised Ultimately, overuse can be considered to occur along a
• Most studies of overuse have been done in high-income continuum. At one end of the continuum lie tests and
countries, but there is growing evidence that overuse is a treatments that are universally beneficial when used on
the appropriate patient, such as blood cultures in a
global problem
• Overuse is likely to cause physical, psychological and young, otherwise healthy patient with sepsis, and
financial harm to patients insulin for patients with type 1 diabetes. At the other
• Overuse deflects resources from public health and other end of the continuum are services that are entirely
social spending in both low-income and high-income ineffective, futile, or pose such a high risk of harm to all
countries patients that they should never be delivered, such as
• Overuse occurs across a wide range of medical specialties the drug combination fenfluramine-phentermine for
obesity.22 However, the majority of tests and treatments

fall into a more ambiguous grey zone,23,24 which includes:
services that offer little benefit to most patients
(eg, glucosamine for osteoarthritis of the knee); those
for which the balance between benefits and harms
varies substantially among patients (eg, opioids
for chronic pain, antidepressant medications for
adolescents); and the many services that are backed by
little evidence to help decide which patients, if any,
might benefit and by how much (eg, routine blood
testing in patients with hypertension) (see figure 1:
Grey zone services). Even when robust consensus has
established criteria defining the appropriateness of tests
and treatments (such as those developed for cardiological
services in the USA), appropriateness can remain
uncertain in many individual cases.25
Chassin and Galvin’s simple definition is further
complicated by the question of whose values and
preferences should determine the balance between
potential benefits and acceptable harms. Certainly
different patients faced with a choice of potentially
beneficial treatments will vary in their views regarding
the tradeoffs of each.26 Thus, individual patient values
and preferences are critical for defining appropriate care
for many conditions that lie within the grey zone.
Unfortunately, clinicians often have a poor understanding
of patient values, incorrectly assuming in some cases
that a patient would prefer to avoid aggressive or invasive
intervention, and in other cases that the patient would
favour more rather than less care. This so-called
preference misdiagnosis contributes to overuse (and
underuse) when clinicians deliver a service that is wrong
for that individual patient.
Measurement of overuse
Overuse can be measured in various ways. Overuse of a
specific service can be measured directly within a
population by use of patient registries or medical
records. This approach requires a reliable definition of
appropriate­ness for a given service, generally using an
evidence-based or consensus-based guideline, or a
multidisciplinary iterative panel process (eg, the RAND
Appropriateness Method27) to define necessary and
unnecessary use. Rates of overuse are then calculated as
either the proportion of delivered services that are
inappropriate or as the proportion of patients who
receive the service inappropriately. This direct measure,
which is the most reliable indicator of overuse, has been
used in a growing body of literature, including several
systematic reviews (see figure 2: Overuse of selected
services in four countries).10–12 However, several
challenges inherent in this approach exist when applied
to many health-care interventions.4 First, as discussed
above, evidence for defining appropriate care is scarce
in many clinical situations, precluding the direct
measurement of overuse for those services. Second,
even if evidence is available, necessary details for
defining the appropriate­ ness of care in individual
www.thelancet.com Vol 390 July 8, 2017 157
Series
Panel: The role of cost in defining overuse and low-value
services
The elimination of clearly ineffective services would reduce
both potential harm to patients and excess costs. However,
clearly ineffective services are greatly outnumbered by grey
zone interventions. Many grey zone interventions benefit
very few patients or provide only small benefit relative to For BMJ clinical evidence see
http://clinicalevidence.bmj.
costs, and thus are not cost effective. Funding such low-value
com/x/index.html
services poses an opportunity cost; less money is available to
address unmet health needs, which subsequently reduces the
funds available to improve the socio-economic determinants
of health. Whereas cost-effectiveness analysis, which can
quantify these tradeoffs, is formally considered in coverage
decisions in HICs, such as Australia, Canada, and the UK,17–19
and an increasing number of LMICs,20 it is not included in
appropriateness determinations in the USA.21
Increasing net benefit
Clearly ineffective services Grey zone services Clearly effective services
Increasing net harm
Figure 1: Grey zone services
patients are often absent from guidelines, while iterative
panel processes, which incorporate more nuance, are
costly and time consuming. Third, few measures have
been developed to assess the prevalence of overuse that
occurs because patient preferences are not elicited.
Electronic health records (EHR) and the development of
large datasets, informed by clinical information from
EHRs, have facilitated the measurement of overuse in
some contexts (eg, the USA Veteran’s Affairs system28,29)
and could have broader applicability in the future.
However, EHRs alone are not likely to enable widespread
measurement of overuse directly.
A growing literature seeks to expand knowledge of
overuse through an indirect measure: identifying
unexpected variations in health-care implementation.
Variations in utilisation that are not attributable to
differences in patient or population characteristics
have been documented both within and among
countries and health-care systems.1–3,5,6,30,31 Although
these variations are often not related to overuse
(or underuse) per se, but rather to different rates of
discretionary care (or services for which the evidence
does not point clearly to a right answer,23 such as revisit
interval for patients with diabetes), unexpectedly high
 Series

0·26% MRI in mild traumatic brain injury patients [91] Country

0·36% Digoxin monitoring in CHF patients [91] USA
0·45% Diagnostic allergy tests [91] Canada
0·7% Fibreoptic laryngoscopy for sinusitis diagnosis [91] Australia
0·93% Serological tests for helicobacter pylori [91] Sweden
1·2% Upper-tract imaging for BPH [77]
1·25% CAD screening in asymptomatic patients [91]
1·6% Anaplastic thyroid cancer patients with RAI [81]
2·07% Imaging in low-risk prostate cancer patients [91]
2·2% Laminectomy/spinal fusion [91]
2·28% EEG monitoring for syncope patients [91]
2·9% Low-risk surgery patients with stress test [86]
2·9% Low-risk surgery patients with ECG [86]
3% Imaging for skeletal metastases in low-risk prostate cancer patients [87]
3·1% Cervical cancer screening in older women [77]
3·3% Stress ECG for patients with acute chest pain [91]
3·4% Medullary thyroid cancer patients with RAI [81]
3·49% Nasal endoscopy for sinusitis diagnosis [91]
3·6% Non-cardiothoracic surgery patients with preop PFTs [93]
3·75% Low-risk surgery patients with no indication and preop stress test [92]
6·49% Contrast material use in thorax CT [91]
8·8% Vitamin D tests [77]
9·7% Frequent DXA tests [77]
11·5% Traction in LBP patients [91]
12·2%, 12·8% Preop cardiac testing for low-risk patients [77,78]
13·3% Initial imaging for LBP [80]
15·4% Preop cardiac test for cataract surgery patients [77]
16·2% Syncope patients with non-indicated carotid ultrasound [90]
18·4% Cataract surgery patients with preop consultation [95]
18·8% Early stage breast cancer patients with preop advanced imaging [79]
Procedure

21·5% TKA after knee arthroscopy [83]

10·8%, 21·9% Low-risk surgery patients with chest radiography [86,91]
22·2% Contrast material use in abdomen CT [91]
22·4% Early radiographs for LBP [84]
22·5% Imaging for LBP [77]
23·2% Low-risk surgery patients with chest x-ray [94]
23·3% Localised papillary thyroid tumour patients with RAI [81]
25% Lung cancer patients with combined BS and PCT imaging [74]
29% Repeated spine CTs [75]
13·4%, 31% Low-risk surgery patients with ECG [86,94]
34·1% Survey responders with cervical cancer screen after hysterectomy [85]
34·5% Upper endoscopy patients with repeat within 3 years [96]
36% Colonoscopy patients with non-guideline recommendations for repeat [29]
37·1% Survey responders with PSA tests within 12 months [89]
38·5% Patients with localised prostate cancer and pADT [88]
39·5% MRI imaging for LBP [91]
Radical nephrectomy patients received IA [97] 40·1%
Cytoscopy patients with repeat within 3 years [96] 40·5%
Stress test patients with repeated stress test in 3 years [96] 43·6%
Repeated chest CTs in 3 years [96] 45·9%
Colonoscopy patients with repeat within 7 years [82] 46·2%
Preop cardiac test for non-cardiac surgery patients [77] 46·5%
PFT test patients with repeat within 3 years [96] 49·1%
Cataract surgery patients with preop testing [76] 53%
Patients with repeated ECG in 3 years [96] 55·2%
Survey responders (older women) with cervical cancer screen [85] 58·4%
TMS in patients with previous breast cancer [91] 73·2%
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Estimated proportion of affected patients in population (%)

Figure 2: Overuse of selected services in four countries

Estimates from the literature of the proportion of patients that received various low-value services, out of the relevant patient population. The populations are based
in four locations. preop=preoperative. TKA=total knee arthroplasty. LBP=lower back pain. BPH=benign prostate hyperplasia. pADT=primary androgen deprivation
therapy. BS=bone scintigraphy. PET=positron emission tomography. TMS=tumour marking studies. DXA=dual-energy x-ray absorptiometry.
EEG=electroencephalogram. ECG=echocardiography. PSA=prostate specific antigen. PFT=pulmonary function test. IA=ipsilateral adrenalectomy. RAI=radioactive
iodine treatment. CAD=carotid artery disease. CHF=congestive heart failure. Adapted and updated from Chalmers, Pearson and Elshaug (unpublished data).

rates of use of a particular service can reflect overuse.8,9 Examples of both direct and indirect evidence
In more recent years, investigators have used large documenting overuse of specific services around the
databases to explore variations in the use of specific world have been noted (table). Some investigators have
services as a method of identifying probable overuse.32,33 moved beyond individual services to evaluate rates of

158 www.thelancet.com Vol 390 July 8, 2017

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Direct evidence of inappropriate care Indirect evidence of inappropriate care

Musculoskeletal Spain: Rates of inappropriate total knee replacement 26% and International: 4-fold variation across countries and 2–3 fold
procedures total hip replacement 25%;34 variation within countries in rates of knee replacement;36
USA: Rate of inappropriate total knee replacement 34%35 England: 13-fold regional variation in rates of arthroscopic knee
lavage;37
USA: 5-fold regional variation in adjusted rates of total hip and knee
replacement38
Cardiovascular Italy: Rate of inappropriate PCI 22% and inappropriate coronary International: 9-fold variation in use of PCI and 5-fold variation in
procedures angiography 30%;39 use of coronary artery bypass grafting across OECD countries;30
USA: Rate of inappropriate PCI 1·1% for acute indications and USA: Rates of elective PCIs vary 10-fold within the state of
11·6% for non-acute indications with variation across hospitals California;42
(6·0–16·7%);40 India: A second opinion centre reported recommending against
Brazil: Rate of inappropriate coronary angiography 20%41 cardiac interventions in 55% of patients in whom intervention was
initially recommended43
Hysterectomy Taiwan: 20% of hysterectomies inappropriate;44 Canada: 2·7-fold variation in rates of hysterectomy across regions
Switzerland: 13% of hysterectomies inappropriate;45 within Ontario;47
USA: Rates of inappropriate hysterectomies between 16 and 70% Netherlands: 2·2-fold regional variation in rates of hysterectomy for
across studies46 bleeding disorders; 2·3-fold regional variation in rates for pelvic
organ prolapse;48
India: Prevalence of up to 9·8% overall, with one third of
hysterectomies performed in women under the age of 35
(probably inappropriate in this age group)49
Antibiotics for Italy: Among children hospitalised for acute diarrhea, 9% received USA: 10·4% of patients with diarrhea received antibiotics
acute diarrhea antibiotics inappropriately;50 (often likely inappropriate);53
China: 57% of patients received antibiotics inappropriately; India: 71% of children with acute diarrhea received antibiotics
among those with an indication for antibiotics, 21% were not (despite recommendations against routine use);54
treated (adults);51 India: Rates of antibiotic use for acute diarrhea 43% in public
Thailand: 55% of children with acute diarrhea received antibiotics facilities and 69% in private facilities (despite recommendations
inappropriately52 against routine use)55

PCI=percutaneous coronary intervention. OECD=Organisation for Economic Co-operation and Development.

Table: Direct and indirect evidence of global overuse in different clinical categories

general overuse in health-care systems by evaluating
variations in groups of possibly overused services,5,56–58
but these methods are not yet well established.
Related concepts
We use the term “overuse” to refer to any services that are
unnecessary in any way. The related terms, overtreatment
and overtesting, indicate the inappropriate delivery of
particular types of services.
Another related term, overdiagnosis, is commonly
defined as the diagnostic labelling of abnormalities or
symptoms that are indolent, non-progressive or regressive,
and that if left untreated will not cause considerable
distress or shorten the person’s life.59 This definition can
be complicated by the varying natural history of specific
diseases, and does not entirely encompass the various
settings in which overdiagnosis occurs or the role that it
has in overuse.60 Overdiagnosis can occur as a consequence
of screening (including recommended screening). For
some screening tests, such as cervical cancer screening,61
the small risk of overdiagnosis and subsequent
overtreatment are outweighed by the reduction in risk of
death. For other screening tests, however, the balance is
less clear62 and overdiagnosis may be an important driver
of overuse in the form of aggressive overtreatment of
clinically insignificant findings.5,63 (The third paper in this
Series14 discusses overdiagnosis in greater detail and other
drivers of overuse, including defensive medicine, which
has been associated with aggressive diagnostic testing in
the USA64 and has been identified by physicians in several
countries65–67 as an important reason for overusing tests
and treatments.)
Overdiagnosis can also occur when the definition of
disease or abnormality is broadened, leading to
populations that were previously considered “normal” or
healthy being labelled as diseased. This phenomenon is
referred to as overmedicalisation and can result in the
treatment of essentially healthy patients in whom potential
benefit is small and likely to be outweighed by harms.
A review of recent USA guidelines showed that for ten of
the 16 guidelines studied, disease definition had been
widened, potentially leading to overuse.68 For example,
lowering risk thresholds for treating cholesterol has led to
a growing proportion of populations in many countries
being prescribed lipid-lowering drugs with unclear
benefits.69,70 Furthermore, a broadened definition of
chronic kidney disease that is used in many countries,
although potentially beneficial for ensuring safe drug
dosing, has led to large numbers of asymptomatic older
people being labelled as ill; as many as 30% of older adults
diagnosed with moderately advanced kidney disease
(stage 3A) have no urine markers of kidney damage.71 In
children, overdiagnosis can occur in frequently diagnosed
conditions, such as Attention Deficit Hyperactivity
Disorder (ADHD), food allergies, gastroesophageal reflux,
obstructive sleep apnea, and urinary tract infections.72

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Worldwide prevalence of overuse
Overuse is gaining increasing recognition as a
worldwide problem; however, the significance of it has
not yet been defined. A 2012 systematic review of the
prevalence of service overuse in the USA noted that the
majority of studies that directly measured overuse were
focused on a relatively small number of services.4
However, indirect evidence, such as studies of
geographical variation, suggests that overuse is not
limited to these services in the USA.73 A more recent
systematic review (unpublished) of global overuse
categorised 83 overused or low-value services from
studies including large sample sizes (more than
800 patients).30,74–97 These authors identified studies
from four countries (with USA studies predominating)
and found that the rates of overuse of various services
ranged from about 1% to 80% (see figure 2). For LMICs
and many HICs, the evidence of overuse is more scarce
and largely indirect, although it appears to be increasing
(see for example, a 2014 report36 on geographical
variation in health care in 13 countries). In this section,
we describe worldwide rates of overuse for a selection
of clinical services. We focused our attention on the
services most commonly described in systematic
reviews and other literature, and services in which
overuse has the potential to substantially affect patients
or health-care systems.
Overuse of medication
One of the best-documented examples of medication
overuse in both HICs and LMICs is the inappropriate
use of antibiotics, which represents a worldwide problem
that has important consequences for antimicrobial
resistance. Many studies have addressed inappropriate
antibiotic use in patients with upper respiratory viral
infections. A 2012 systematic review of overuse in the
US health-care system found 59 studies documenting
widely variable rates of overuse of antibiotics for upper
respiratory infections.4 In Europe, rates of antibiotic
prescribing for viral upper respiratory infections are
high in Poland, Sweden, and the UK, with half of patients
receiving unnecessary antibiotics.98–100 Additionally,
across the continent, studies have documented variable
rates of antibiotic prescribing for patients with acute
cough, with no associated differences in rates of
recovery,101 suggesting overuse.
Evidence of antibiotic overuse in LMICs is largely
indirect. Global consumption of antibiotic drugs has
risen by 36% between 2000 and 2010, with growing
economies such as Brazil, China, India, Russia, and
South Africa accounting for 76% of this increase.102 The
extent to which this increase represents overuse is not
known, however, a 2015 systematic review12 of medication
use in China and Vietnam found evidence for antibiotic
overuse in both countries. Furthermore, a 2005
systematic review11 of patterns of antibiotic use, which
included studies from around the globe, found high rates
160 www.thelancet.com Vol 390 July 8, 2017
of inappropriate administration, including substantial
patient consumption of so-called leftover antibiotics.
Similarly, a 2013 Cochrane review103 of the effect of
interventions to improve antibiotic prescribing in
patients admitted to hospital included studies from both
HICs and LMICs, suggesting wide recognition of the
problem of inappropriate antibiotic use, however, the
review did not directly quantify prescribing rates.
In other clinical specialties, unexpectedly high
prescribing rates for specific drugs in individual health
systems suggests overuse. Bevacizumab, an expensive
and generally ineffective treatment for breast cancer, is
not recommended by the National Institute for Health
and Care Excellence (NICE) in the UK, and its US Food
and Drug Administration marketing authorisation for
breast cancer was withdrawn. However, the drug is
reimbursed by health insurers in Colombia for all
(licensed and unlicensed) cancer indications at great
expense to the country’s health-care system.104 Similarly,
erythropoiesis stimulating drugs, epoetin alfa and
beta and darbapoetin alfa, have been widely and
inappropriately used in Romania to treat ribavirin-
induced anaemia in patients with Hepatitis C and
organ transplantations, in the absence of supporting
evidence.105
Overuse of screening tests
High rates of inappropriate use of screening tests have
been documented, often in the context of concurrent
underuse in appropriate populations. In the USA,
where there is widespread public support for cancer
screening,106 overuse of screening for cervical cancer107,108
in women at very low-risk, and overuse of mammography
in women with short life expectancy, who are unlikely to
benefit from diagnosis and treatment,109 has been
documented. Furthermore, inappropriate use of
colonoscopy screening has been found in both the USA
and Canada.110–12
Few studies have evaluated rates of inappropriate
cancer screening outside of North America. A notable
exception is South Korea’s aggressive use of ultrasound
screening, which has led to a 15-fold increase in
incidence of papillary thyroid cancer. The death rate
from this cancer has remained unchanged throughout
the period of increased screening, and it is estimated
that 99·7–99·9% of screen-detected thyroid cancers in
Korea represent overdiagnosis.113 Patients subjected to
un­necessary thyroidectomy face an 11% risk of hypo­
parathyroidism and a 2% risk of vocal cord paralysis,
demonstrating clear downstream harms of inappropriate
screening. Despite low levels of appropriate mammo­
graphy screening and widespread doubts regarding the
cost-effectiveness of mammograms,114 there are reports
of touring mammography vans in India that provide
indiscriminate breast cancer screening in women as
young as 18 years old,115 much of which represents
clear overuse.

Overuse of diagnostic tests
Overuse of testing appears to be common, driven by
availability, apparent objectiveness, and the increasing
sensitivity of tests to detect disease. Although few
systematic analyses of inappropriate use of diagnostic
tests have been performed in general, some specific
diagnostic services have been evaluated around the
world. For example, overuse of endoscopy seems to be
common globally. In primary care practices in
Switzerland, 14% of colonoscopy referrals and 49% of
referrals for upper endoscopy represented overuse.116,117
Elsewhere in Europe, appropriateness rates for
endoscopy have been reported in Portugal, Spain, Italy,
and Norway; overuse accounted for between 13% and
33% of tests,118–21 and at an Israeli centre 16% of
endoscopies were unnecessary.122 Studies in the USA
have reported overuse rates as high as 60%.123 In Saudi
Arabia, which has open access to endoscopy, nearly half
of procedures were deemed inappropriate.124 A Dutch
study125 found that approximately a quarter of patients
received appropriate colonoscopy after removal of
colorectal adenomas, with both overuse and underuse of
surveillance observed.
Overuse of therapeutic procedures
Surgery and other invasive procedures are likely to be
commonly overused in high-income countries. Although
prevalence of directly-measured overuse were not
reported, Elshaug and colleagues5 identified more than
150 low-value services in use in Australia, and in the
USA, up to 42% of Medicare beneficiaries had received
at least one of 26 low-value treatments, with these
interventions accounting for as much as 2·7% of overall
Medicare spending.56 Such findings are suggestive of
widespread overuse of these services.
There are ample global data regarding the overuse
of several cardiovascular procedures, despite clear
and broadly accepted appropriateness criteria.126
In­appropriate percutaneous coronary intervention has
been documented in many countries, with a prevalence
of 4–12% in the USA; 40,127 10–14% in Germany,128,129 16%
in Italy;130 22% in Israel;8 20% in Spain;9 and 4% in
Korea.131 In one second-opinion centre in India, 55% of
recommended cardiac stents or surgery were deemed
inappropriate.43
Site of care delivery
The site of care delivery and the intensity of care provided
are relevant to overuse since more intense care carries a
greater risk of complications, and is more costly. If more
intense care does not improve outcomes for a condition
when compared with less invasive or intensive care, it
represents overuse. Hospital care overuse has been
documented in both HICs and LMICs. A 2000 systematic
review10 found widely varying rates of inappropriate
hospital admissions around the world, ranging from
1% to 54% of hospital admissions. Rates of hospital care
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Series
overuse in specific countries measured using established
criteria to determine appropriateness, were 18–25% in
France,132 33% in Germany,133 19% among internal
medicine admissions in Portugal,134 7% at a referral centre
in Spain,135 27% in rural hospitals in China,136 and widely
variable across three Egyptian hospitals, with rates
ranging between 0% and 79%.137 Additionally, studies
have shown broad variations in rates of hospital use both
within and among countries,138,139 suggesting possible
overuse, as well as underuse, of hospital care in different
locations. Many of these variations are particularly
striking with regard to “ambulatory care-sensitive”
conditions, or conditions for which high-quality primary
care is likely to prevent the need for hospital admission.140
Overuse of hospital care for ambulatory care-sensitive
conditions demonstrates that overuse of one (usually
more aggressive) service can result from underuse of
another, often less aggressive service.
End-of-life care
In many countries, evidence exists for the overuse of
aggressive care for dying patients and simultaneous
underuse of appropriate palliative care. Despite evidence
that the majority of people around the world
would prefer to die at home,141–46 about half die in
hospital worldwide, with considerable variation among
countries.147 Inappropriately aggressive cancer care near
the end of life has been identified as a common problem
in Canada,148 the USA,149 and the UK,150 with regional
variations observed.151 Overuse of aggressive end-of-life
care in the UK, for example, includes futile insertion of
percutaneous endoscopic gastrostomy tubes151 and
administration of chemotherapy that hastens death.152
Furthermore, ineffective intensive care unit treatment at
the end of life has been reported in Canada,153 the USA,154
and Brazil.155 A study from Korea found that the majority
of terminal cancer patients received futile intravenous
nutrition during the last week of life, with discussions of
palliation in only 7% of cases.156
Although few systematic assessments of end-of-life care
have been performed in LMICs, it is likely that futile care
at the end of life is not limited to HICs. In one study in
India, nearly half of patients with cancer were diagnosed
late and received ineffective radiotherapy.157 In Brazil, one
in five patients with cancer were administered useless
medication, most often a statin.158 Overall, it is likely that
overuse of aggressive care and underuse of palliative care
at the end of life is commonplace in both HICs and LMICs.
Harms to patients and health-care systems
Overuse is likely to harm patients physically,
psychologically, and financially, and could threaten the
viability of health-care systems by increasing costs and
diverting resources. However, our ability to collect strong
evidence that describes the direct consequences of
overuse on patients and health systems has been impeded
by the same factors that challenge our ability to document
 Series
overuse itself, including an incomplete evidence base for
effectiveness and limited reporting of treatment harms.159
Much of what we know regarding the harms of overuse is
derived from estimates and extrapolations.
Harms to patients
Few studies have directly documented patient harms from
overuse, however, estimates of physical harm to patients
from overuse can be inferred from data on adverse events
and studies regarding overuse of specific treatments.
For example, Cushner and colleagues160 used outcomes
from a global orthopaedic registry for total knee and hip
arthroplasty to estimate a rate of 7–8% for serious adverse
events, which included severe infection, revision,
cardiovascular events, and death. Other researchers
estimate that more than 20% of total knee replacements
in Spain and 30% in the USA are inappropriate.35,161 Thus
we can estimate that 2–3% of patients undergoing
arthroplastic surgery in those two countries are
unnecessarily harmed by an inappropriate procedure,
with approximately 14 000 patients suffering harm from
unnecessary knee and hip arthroplasty per year in the
USA alone. Other examples of documented harm from
overuse include high rates of overuse of implantable vena
cava filters and low rates of appropriate removal,162 with
known excess venous thrombotic complications in 10% of
patients who receive them,163 and continued overuse of
tight glycemic control in intensive care units, despite
evidence of higher rates of hypoglycemic complications
without reductions in mortality.164
Psychological harms from overuse have only been
documented for few clinical situations but may be
common. Several authors have noted that treatment in
hospital may lead to unnecessary physical isolation of
patients,165 with negative consequences including
loneliness, feelings of stigmatisation, and depression.166
Furthermore, screening for breast cancer is known to
lead to the diagnosis of precancerous lesions, such as
ductal carcinoma in situ,167 which has been associated
with anxiety for several years after diagnosis and patient
overestimation of future cancer risk.168–70
Patients can also suffer from being inapprop riately
labelled as “ill” as a result of unnecessary testing. As early
as 1967, Bergman and Stamm found that among
adolescents with heart murmurs, which had been
previously (and possibly unnecessarily) evaluated and
deemed ‘innocent’, 40% continued to experience
restricted activity and 63% had parents who continued to
believe their child was unhealthy.171 Harm from labelling
can also occur in the context of mental illness. For
example, it is widely acknowledged that ADHD is
overdiagnosed and overtreated in the USA and other
HICs. ADHD is also overtreated in some LMICs,172
although some children with ADHD fail to receive
appropriate treatment. There is scant research on the
effect of an ADHD diagnosis on a child’s sense of
self-esteem and ability to modulate their own behaviour,
162 www.thelancet.com Vol 390 July 8, 2017
but the label has been shown to affect teacher’s
expectations and peer interactions, which can
substantially influence a child’s self-perceptions.173–75
Financial costs represent a potentially important but
poorly documented source of harm from overuse to
patients. In the USA, cost has been identified as a known
consequence of all medical care176 and of cancer
treatment in particular,177 with medical bills contributing
to over half of personal bankruptcies,178 although the
contribution of overuse is not known. Similarly, in
Australia, parents of children with cancer reported high
out-of-pocket expenses,179 and WHO has documented
medical indebtedness across the globe. Health care is a
major source of impoverishment and indebtedness
among the poor of India,180,181 and 15% of rural
Vietnamese families with one member with a chronic
illness experience financial catastrophe.182 Determining
the financial burden of overuse on patients requires
active investigation in the future.
Harms to health-care systems
Although there are few direct measurements of the
proportion of health-care spending attributable to
overuse, evidence is emerging that suggests the cost
might be considerable. A study183 regarding the
inappropriate use of bone scans for US Medicare
beneficiaries with prostate cancer found that 21% of
patients at low risk and 48% of patients at moderate risk
of bone metastases underwent at least one scan, despite
recommendations against scanning in these groups, at
an annual cost of US$11 300 000. Experts estimate that
prevalence of overuse contributes substantially to
health-care spending in the USA.184 Based on a conservative
estimate,2 the USA spent at least $270 billion on care that
could be defined as overuse in 2013, despite the fact that
millions of Americans do not have adequate access to
basic health care. Overuse might also strain health-care
budgets in other countries.185 In Australia, where many
common services are believed to be overused,5 the growth
in health care expenditure from the rising volume of
medical services has been identified as the greatest threat
to the financial position of the government, and a bigger
cause of health-care cost increases than population
growth or ageing.186
Of particular concern is the potential financial effect of
overuse on LMICs. The use of expensive advanced
technology in HICs, such as new cancer biologics,
imaging devices, and multi-focal cataract replacement
lenses, spreads through globalised markets to LMICs,
potentially crowding out less technological (and
potentially higher value) means of promoting population
health.187 In India, private health insurance and formal
sector employees’ insurance programmes cover
expensive cancer drugs for a tenth of the country’s
population, although the general population does not
have access to many basic health-care interventions.180
Although the extent to which the use of expensive

services represents true overuse as opposed to lower-value
care from a public health perspective is not clear, overuse
is a potential threat to both the viability of public budgets
and to population health in LMICs.
Worldwide trends in overuse
Is overuse getting better or worse? This is a difficult
question to answer for several reasons. First, we are only
beginning to conceptualise overuse as a general system
problem and to develop system-level metrics.188 Second,
there are no measures in general use and providers in
most countries have few incentives to report overuse.
Third, health-care systems are complex and dynamic;189
reducing or eliminating overuse of one service or in one
site of care could encourage overuse in another,
particularly in systems whereby providers are paid a
fee-for-service and expect to maintain revenue.
We do know that there has been increased attention
among health ministers, clinicians, policy makers and
the public, with respect to overuse during the past
5–10 years, particularly in HICs but also in some
LMICs. However, awareness of the problem has not
automatically led to clinicians delivering the right care.
In the USA, for example, concerns about excessive
caesarean delivery have existed for decades, however,
incidence has continued to rise (from 21% in 1996 to
31% in 2006).190 Furthermore, despite longstanding
concerns regarding the overuse of imaging with CT and
MRI, their use increased between 8% and 10% annually
from 1996 to 2010.191
In LMICs, overuse appears to be increasing, at least for
certain services. In Tanzania, rates of caesarean delivery
rose from 19% in 2000 to 49% in 2011 among low-risk
deliveries,192 with similar increases over time in India,
Nepal, and Bangladesh.193 Financial incentives and
government policies can contribute to increased overuse.
In China, government cuts in subsidies led hospitals to
charge patients for care,194,195 potentially contributing to
notably high rates of caesarean delivery (46% in one study
in a rural area).196 Amid allegations of physician corruption
and kickbacks from the pharmaceutical industry and
diagnostic centres, there are reports from India of
inappropriate use of drugs, diagnostic tests, and
procedures,197 including strikingly high rates of
hysterectomies.198 These trends appear to be novel and
probably reflect increases in overuse over the past decade,
but there are few data documenting longitudinal changes.
HICs are experimenting with specific initiatives to
address overuse, such as NICE’s “do not do” list,199
attention to low-value practices in Australia,5 and the
Choosing Wisely campaign (http://www.choosingwisely.
org/).200 However, there are few studies in either HICs or
LMICs addressing the impact of such initiatives.
Additionally, EHRs, which have been used as a tool to
reduce overuse locally,201 could be used more broadly in
the future. The fourth paper in this Series15 reviews
efforts around the world to reduce overuse.
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Conclusion
There is strong evidence for the widespread overuse of
several specific medical services in many countries,
suggesting that overuse is common around the world and
might be increasing. However, this paper highlights a key
challenge: measuring overuse and developing robust
evidence for its prevalence in health services and patient
populations. There is a clear need for a research agenda to
develop such evidence.13 Overuse is likely to cause harm
to both patients and health-care systems and thus,
physicians, politicians and policy makers in both HICs
and LMICs must understand overuse and act to reduce it.
Contributors
All authors participated in the development of the report, including
conception, provision of data and references, writing of the
manuscript, revision of the draft, and approval of the final version.
SB and DK wrote drafts, which were improved and revised by all other
authors. KeC developed figure 2.
Declaration of interests
AGE receives salary support as the HCF Research Foundation
Professorial Research Fellow, and holds research grants from The
Commonwealth Fund and Australia’s National Health and Medical
Research Council (ID 1109626 and 1104136); receives consulting sitting
fees from Cancer Australia, the Capital Markets Cooperative Research
Centre-Health Quality Program, NPS MedicineWise (facilitator of
Choosing Wisely Australia), The Royal Australasian College of
Physicians (facilitator of the EVOLVE programme) and the Australian
Commission on Safety and Quality in Health Care. JD reports grants
from the National Health and Medical Research Council. VS and SB
receive support from the Robert Wood Johnson Foundation. DK was
supported by a Cancer Center Support Grant from the National Cancer
Institute to Memorial Sloan Kettering Cancer Center (award number
P30 CA008748). KaC, KeC, SN, DS, PG, and IH declare no competing
interests. Views expressed by the authors are their own and do not
necessarily represent the views of their employing, affiliated, or
associated organisations.
Acknowledgments
The study was funded by The Commonwealth Fund, a national, private
foundation based in New York City that supports independent research
on health-care issues and provides grants to improve health-care practice
and policy. The views presented here are those of the authors and not
necessarily those of The Commonwealth Fund, its directors, officers, or
staff. The authors are indebted to Sarah Quddusi and Yi Wang for
assistance with references; Prakash Shakya for researching the
international literature on cardiology and overuse at the end of life; and
Joseph Colucci and Carissa Fu for technical assistance.
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 Series

Right care 2
Evidence for underuse of effective medical services around
the world
Paul Glasziou, Sharon Straus, Shannon Brownlee, Lyndal Trevena, Leonila Dans, Gordon Guyatt, Adam G Elshaug, Robert Janett, Vikas Saini

Underuse—the failure to use effective and affordable medical interventions—is common and responsible for Lancet 2017; 390: 169–77
substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment Published Online
continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow January 8, 2017
http://dx.doi.org/10.1016/
or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different
S0140-6736(16)30946-1
interventions varies by country, and is documented in countries of high, middle, and low-income, and across different
This is the second in a Series of
types of health-care systems, payment models, and health services. Most research into underuse has focused on four papers about right care
measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences See Comment pages 101, 102,
for patients and populations. Although focused effort and resources can overcome specific underuse problems, and 105
comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective Centre for Research in
interventions, and methods to make them affordable. Evidence-Based Practice, Bond
University, Robina, QLD,

Introduction which already have relatively low cervical cancer rates Australia (P Glasziou FRACGP);
Li Ka Shing Knowledge
Underuse—the failure to deliver a health service that is and well established screening programmes, have Institute of St. Michael’s
highly likely to improve the quality or quantity of life, documented a 68% reduction in high-risk human Hospital, Department of
which is affordable, and that the patient would have papilloma virus (HPV) infection rates as a result of HPV Medicine, University of
Toronto, Toronto, ON, Canada
wanted—is responsible for considerable avoidable (S Straus MD); Lown Institute,
morbidity and mortality. For example, WHO estimated1 Brookline, MA, USA
that in 2015, 1·5 million children died of vaccine- Panel 1: History of the slow uptake, and current underuse, (S Brownlee MSc, V Saini MD);
preventable illnesses. The Born too Soon Preterm Action of antenatal steroids to prevent mortality and morbidity Discipline of General Practice

Group estimates that an 84% reduction in the more than in premature births (L Trevena PhD) and Menzies
Centre for Health Policy
1 million annual deaths in preterm babies could be 1972 (A G Elshaug PhD), School of
achieved through universal health coverage and use of First randomised control trial (RCT) shows antenatal Public Health, University of
selected interventions, such as antenatal corticosteroids Sydney, Sydney, NSW,
corticosteroids hasten fetal maturation, reduce risks of Australia; University of the
(panel 1) and kangaroo mother care, which involves respiratory distress syndrome, intraventricular hemorrhage, Philippines Manila, Manila,
maintaining prolonged skin-to-skin contact between the and neonatal death2 Philippines (Prof L Dans MD);
baby and mother; however, the uptake of such Department of Clinical
interventions has been painfully slow. 1981 Epidemiology & Biostatistics,
Paper by Crowley consolidating the results of four RCTs3 McMaster University, Ontario,
Underuse varies substantially between and within ON, Canada (G Guyatt MD); and
countries. For example, high-income countries (HICs), 1984 Harvard Clinical and
Translational Science Center,
Collaborative Group on Antenatal Steroid Therapy finds no
Boston, MA, USA (R Janett MD)
detectable growth or physical, motor, or developmental
Key messages Correspondence to:
deficiencies4 Prof Paul Glasziou, Centre for
• Underuse is responsible for substantial suffering, Research in Evidence-Based
1989 Practice, Bond University,
disability, and loss of life worldwide, in both high-income
Systematic review of RCTs shows significant benefit from Gold Coast, QLD 4229, Australia
and low-income countries
steroid therapy5 paul_glasziou@bond.edu.au
• Underuse is prevalent across different types of health-care
systems, payment models, and health services 1995
• The causes of underuse are multi-layered: from National Institutes of Health Consensus Conference
inadequate access, health system failures, clinicians being recommends steroids based on a meta-analysis6
unaware or unskilled to provide required interventions,
2010
and patients not accessing or declining them
Meta-analysis shows greater benefit in low-income and
• Underuse occurs alongside overuse, particularly in areas
middle-income countries7
where there is competitive tension between profitable
and low-cost interventions 2011
• Policy makers, funders, clinicians, and civil society urgently WHO’s 29 Country Survey of Maternal and Newborn Health
need to recognise, invest, and resolve the slow uptake of documented only 52% of women in preterm labour receive
effective, affordable, but non-promoted interventions corticosteroids8

www.thelancet.com Vol 390 July 8, 2017 169

 Series

known about the prevalence of underuse and the harm

A USA
100 Qatar it causes patients, populations, and health systems
Peru worldwide.
90 Tanzania

80 Measuring underuse
Although underuse is known to occur in all countries
People with hypertension (%)

70
and health systems in which it has been studied,
60 remarkably little research has focused on determining
50
the global prevalence of underuse, or even the degree
to which most medical services are underused in
40 appropriate patients. Most studies of underuse have
30 focused not on prevalence or harm, but rather on
methods of remedying the underuse of specific services.
20
Studies of variations in practice, between and within
10 countries, provide an indirect method of assessing
0
possible underuse. Considerable variations occur in the
Aware of hypertension On medication BP controlled use of many elective tests and treatments (eg, coronary
bypass rates vary by more than three-fold across countries
B USA
100 Kenya and by up to six-fold within countries; knee replacement
rates vary by more than four-fold across countries and
90
by more than five-fold within some countries).13 Such
80 studies suggest some degree of inappropriate use;
however, there is usually no way to determine from
70
variation per se that areas in which rates are high are
People with HIV (%)

60 experiencing overuse, or that areas in which rates are low

50
40
30
20
10
0
Aware that HIV+ On ART Virally suppressed
Figure 1: Awareness, treatment, and control of hypertension 15,16
(A) and HIV
16,17
(B) between countries
BP=blood pressure. ART=antiretroviral therapy.
immunisation programmes.9 By contrast, in India, where
more women die from cervical cancer than childbirth,
access to HPV vaccination and even to low-technology
screening, such as visual inspection of the cervix with
acetic acid, is limited.10
Underuse and overuse can occur simultaneously.
A common tragedy in both wealthy and poorer countries
is the use of expensive, and sometimes ineffective,
technology while low-cost effective interventions are
neglected. For example, a 2013 study in Tanzania found a
concurrent increase in maternal mortality and caesarean
section in low-risk births;11 at the same time, whether due
to distance or financial barriers, only 50% of all deliveries
were done by a skilled provider.12
In this paper we review what is known about the
scope and consequences of underuse around the world.
We undertook a literature search for primary resources
and systematic reviews on underuse, supplemented
with an iterative citation search of relevant articles.
From this literature we offer a description of what is
are suffering from underuse.
Global burden of disease studies have focused on the
prevalence of illness and risk factors rather than
underuse of medical services; surveys in low-income
and middle-income countries (LMICs), such as the
Demographic and Health Surveys and UNICEF’s
Multiple Indicator Cluster Surveys, have included
availability of some health services, such as antenatal and
perinatal care, and vaccination, as markers to track the
development of health-care systems.14 However, such
studies have generally not provided a full view of
underuse of even those few services; even when a service
is available in a system, the study might not measure the
percentage of the population that does not access it. For
example, in estimates of the underuse of corticosteroids
to prevent preterm birth, studies focus on women who
visit a clinic to see a health-care professional and do not
receive appropriate steroid treatment, thus not capturing
women who never attend a clinic, thereby producing an
underestimate of underuse.
For a few conditions, population-based prevalence of
underuse, including underdiagnosis and undertreatment,
has been assessed directly via national surveys, which
include questions about underuse before, during, and
after clinical care. For example, in the USA, the National
Health and Nutrition Examination Surveys15 estimated
that 31% of adults aged 18 years and older, and 70% of
adults aged 65 years and older had hypertension (based
on an average of three blood pressure measurements
during the survey, and self-reported medication).
Pharmacological treatment rates had improved modestly
from 60% between 1999 and 2002, to 70% between 2005

170 www.thelancet.com Vol 390 July 8, 2017


and 2008, and the proportion of patients with controlled
blood pressure increased from 33% to 46%. Although
these figures still reflect considerable underdiagnosis
and undertreatment of hypertension, they are very good
compared with results from other countries16 (figure 1),
such as sub-Saharan Africa, where of those with
hypertension, only between 7% and 56% (pooled
prevalence 27%) were aware of their hypertensive status
before the surveys; 18% of individuals with hypertension
were receiving treatment; and only 7% had controlled
blood pressure.18 Surveys of HIV show similar gaps
between awareness of virus status, treatment, and control
of viral load (figure 1) for the USA17 and Tanzania.16
For most health conditions, however, similar population
studies assessing underuse are uncommon, and thus
we can draw only an incomplete picture of the global
prevalence and effect of underuse.
To assess the available data for underuse at the
population level, we divided the continuum of care into
four stages, adapted from a previous model.19,20 At each of
the four stages, patients might not receive or use
potentially beneficial treatment (figure 2). The four stages
are: (A) a total or partial lack of access to health care
(because the system does not offer coverage or patients
are unable to reach or pay for available care, or both);
(B) unavailability of effective services within the local
health-care system; (C) a failure of clinicians to deliver or
prescribe effective, affordable interventions; and (D) a
failure of patients to commence or adhere to effective,
affordable interventions. The effect of these four stages is
cumulative, as illustrated in figure 2. Once the patient has
accessed care, underuse at stages 3 and 4 might occur
because of a lack of awareness, knowledge, or skills, in
addition to other reasons such as habit, inertia, and
inconvenience on the part of either clinician or patient.23,24
Physicians and other health-care workers may not
provide appropriate tests or treatments,24 for various
reasons including ignorance of the evidence, competing
therapies promoted by financial interests, lack of
confidence or technical skills, insufficient time, or
implicit substitution of their own values and preferences
for those of their patient. These problems can be
compounded if clinicians are busy delivering unneeded
or undesired care.25 The potential for and prevalence
of underuse can thus accumulate because of multiple
problems at each stage of the health-care continuum.
Worldwide prevalence of underuse
The following section of this paper provides some
estimates of underuse at each of the four stages shown
in figure 2.
(A) Access to health care
Patients may have no, or little access to health care
because of remoteness, poverty, lack of coverage,
immigration status, or other factors. Poor access to
medical care because of financial barriers occurs even in
www.thelancet.com Vol 390 July 8, 2017 171
Series
Examples and estimates
Use Non-use
A Access to any health care No health Over 400 million people lack access
care access to basic health care (World Bank)16
B Health system includes provision of all Intervention Unmet need for surgery of
effective, affordable interventions not available 143 million of 321 million needed
(44%) varies from 0% (US, western
europe) to 86% (sub-Saharan Africa)21
C Clinician aware and able Not provided 43–45% of clinical encounters did
to provide effective or offered not provide guideline recommended
intervention care (CareTrack, Australia; McGlynn,
USA)22
D Patient Non- 26–42% non-adherence to evidence-
agrees and adherence based preventive therapies after
adheres myocardial infarction4
0% Use of evidence-based health care 100%
Figure 2: Underuse can accumulate over four stages of care, from access to adherence
HICs. A recent survey of 11 Organisation for Economic
Co-operation and Development countries found the
percentage of the population unable to access medical
care because of costs, as measured by prescriptions,
tests, or health-care professional visits that patients did
not attend, ranged from 4% in the UK, to 37% in the
USA, with a median of 15% (Germany).26
The prevalence of underuse due to financial barriers in
LMICs is likely to be substantially worse, but data are
more scarce. To monitor global access to health care and
ensure comparability between countries WHO and the
World Bank have recommended eight core tracer health
service indicators: family planning, antenatal care, skilled
birth attendance, child immunisation (three doses of
diphtheria, tetanus and pertussis [DTP]-containing
vaccine), antiretroviral therapy, tuberculosis treatment,
and improved water sources and sanitary facilities.16
These health services are identified as essential and
should be available universally in all countries, regardless
of socioeconomic stage or epidemiological status. The
report estimated that in 2013 more than 400 million
people were still unable to access one or more of the
following basic health services: women whose demand
for family planning was not met, pregnant women who
did not attend at least four antenatal visits (minus 38% to
account for unintended pregnancies), infants who did
not receive three doses of DTP-containing vaccine,
HIV-positive adults and children not receiving HIV
treatment, adults with new cases of tuberculosis
not receiving tuberculosis treatment, and children
aged 1–14 years not sleeping under an insecticide-
treated bednet.16
(B) Availability in the health system
Even when a population has access to health care, some
effective interventions are not available because of
limited resources, regulatory control, or other factors.
For example, a low per capita supply of physicians or
hospital beds can mean that patients do not receive
 Series
For dates and data from Hollows Panel 2: Fred Hollows’ steps in reducing avoidable and
see www.hollows.org.au/
treatable blindness in low-income countries, via low-cost
cataract surgery
Mid-1980s
Hollows initiated goal to reduce the cost of eye health care
and treatment in low-income countries (training Ruit from
Nepal and Desbele from Eritrea)
Late 1980s and early 1990s
Lens costs prohibitive, so Hollows, with Ruit and Desebele,
build intraocular lens manufacturing facilities in Nepal
and Eritrea
By 2010
The Fred Hollows laboratories in Nepal and Eritrea had
manufactured over four million low-cost intraocular lenses,
for both local use and global use
needed care. Excessive waiting times for elective surgery,
such as cataracts or hip replacements, financial barriers
to specific treatments (expensive cancer chemotherapy),
and a paucity of practitioners (cognitive behavioural
therapy [CBT]), are clear examples of limited availability
even in countries with universal health-care coverage.
The recent Cancer Atlas27 reports that in HICs, most
patients with terminal cancer have access to opioids for
pain relief, whereas in LMICs as few as 11% do
(57% average access for Africa; 69% in southeast Asia),
despite opioids being on the WHO essential medicines
list, having a low cost relative to many drugs, and strong
evidence that they are the most effective treatment for
severe pain due to cancer.
Human resource shortages are a persistent problem
contributing to underuse in LMICs. For example,
countries in sub-Saharan Africa (except for South Africa
and Botswana) average less than two pathologists per
million population,27 compared with 15 per million in
Taiwan, 26 per million in Canada, and 44 per million in
the USA.28 Lack of human resources can also afflict
HICs. In 2004, the UK’s National Institute for Health
and Care Excellence issued guidelines recommending
the use of psychological therapies—particularly CBT—in
depression, anxiety, and other conditions; however,
the UK workforce was insufficient to deliver the
recommended treatments, and a training initiative,
the Improving Access to Psychological Therapies
programme,29 was established. Access to mental health
services is worse in LMICs than in HICs: a 2015 WHO
report estimated that treatment coverage for depression
was 41% in the HIC surveys, compared with only 18%
in LMICs.16
The global unmet need for surgery, which is estimated
to be over 320 million surgical procedures per year, is
concentrated mostly in LMICs. A 2015 global analysis of
the ratio of minimum procedures needed to procedures
done, showed large deficits in southern and southeast
172 www.thelancet.com Vol 390 July 8, 2017
Asia and most of sub-Saharan Africa, where less than
half of the minimum needed procedures are done.21
In some of the countries studied, failure to deliver
needed surgery can occur at both stages A and B, because
dependent patients do not have access to care, or there is
limited capacity to perform surgery, or both.
There are no ideal solutions to these problems, but they
can be solved. However, implementation will usually
require persistence to overcome a series of barriers
and bottlenecks. For example, avoidable and treatable
blindness remains a global burden, with cataracts causing
10·8 million cases of blindness and 35·1 million cases
of vision impairment in 2010.30 The ophthalmologist
Fred Hollows began doing cataract operations in Eritrea,
and quickly recognised that it was better to train others to
do the surgery than to do it himself. However, the cost of
lenses meant that cataract surgery remained financially
unviable for most poeple. Therefore, Hollows built a local
factory to manufacture lenses at a fraction of the usual
cost (panel 2). Since then, similar programmes have been
established in many LMICs. Other solutions for underuse
(and overuse) will be discussed in the fourth paper in
this Series.
Particularly wasteful is the global failure to capitalise
on effective non-pharmalogical therapies, which,
although less intensively marketed, are in many cases
equally or more effective than their pharmacological
counterparts. For example, pulmonary rehabilitation,
which involves progressive exercise and education, has
been shown to reduce hospital re-admissions and
deaths for patients with chronic obstructive pulmonary
disease by 70%; daily application of sunscreen can cut
invasive melanoma rates by 50%; and insecticide
impregnated bednets can prevent 50% of malaria
cases.31 Unlike their pharmaceutical counterparts,
non-drug treatments are less intensively studied, more
poorly described in research, weakly regulated, and
inadequately marketed, particularly when the treatment
or prevention is cheap or free.
(C) Clinician uptake
Even when access and availability of services are not an
issue, discrepanices can occur between best care, as
suggested by evidence and guidelines, and what
clinicians do in practice. For example, the CareTrack
study21 found that adult Australians received appropriate
care in only 57% of 35 573 eligible health-care encounters.
In the USA, a study published in 2003 found that
patients received only 54·9% of recommended care.32
Furthermore, Hackbarth and Berwick estimated between
US$102 billion and $154 billion in wasteful spending in
the USA in 2011, which resulted from the failure to
deliver best care—ie, poor execution or lack of widespread
adoption of known best care processes.23
The international interest in research translation and
quality improvement reflects the growing recognition
of the slow and inconsistent uptake of effective medical
 Series

services by clinicians worldwide. Evidence–practice Stage (C) Underuse: in-hospital gap

gaps generally narrow with time, but uptake can be
100
both slow and incomplete, resulting in avoidable

Patients discharged on β blocker after myocardial infarction (%)

suffering. The slow implementation of Semmelweis’s 90
demonstration of the importance of hand washing to 80
Stage (D)
Underuse:
prevent transmission of infections in delivery wards
adherence
illustrates the problems of uptake. A century after his 70 gap
death, there is still chronic underuse of appropriate 60
(discharge to
6 months)
hand washing in both HICs and LMICs, resulting in
avoidable morbidity and mortality.33 50 6 months
post-MI
Clinicians also do not administer many evidence-based 40
treatments to appropriate patients. For example, a review 34% US patients
30 (NEJM 1992)31
of 29 studies in several countries34 found underuse
of anticoagulation in patients with non-valvular atrial 20
fibrillation (NVAF) who are at high risk of stroke; even 10th percentile
10 Mean
for patients with a CHADS-2 (congestive heart failure, 90th percentile
hypertension, age >75 years, diabetes mellitus, and 0
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
previous stroke or transient ischaemic attack) score of 2 or Year
more, seven of nine studies reported treatment levels β-blocker Heart Attack
below 70%. In a 2014 national registry study from China, (BHAT) trial shows 40% ACC & AHA Included in
mortality reduction guidelines accreditation standard
only 19% of patients with NVAF and acute stroke were
discharged on anticoagulation therapy, and physician’s Figure 3: Timeline for adoption of β blockers after myocardial infarction
concern around bleeding risk was the most common Data extracted from Lee, 2007.38 MI=myocardial infarction. ACC=American College of Cardiology. AHA=American
reason for not prescribing it.35 A study of nursing home Heart Association.

patients in France found that less than 50% of those at

high risk of stroke were on anticoagulation; physicians
caring for these patients wrongly thought that paroxysmal
atrial fibrillation causes fewer thromboembolic events
than persistent atrial fibrillation.36 Although stroke
prevalence is low in Africa compared with the developed
world, atrial fibrillation is a leading cause of stroke, and
studies in various African countries have shown underuse
of anticoagulation, ranging from 34% in Cameroon to 75%
in South Africa.37 These studies also show that those living
in urban centres were more likely to receive anticoagulation
than those in rural areas. Furthermore, access to new oral
anti­coagulants is limited in many countries.
The slow and inconsistent uptake of β blockers for
patients who have had a myocardial infarction illustrates
the dynamic nature of underuse (figure 3). 8 years after
the Beta-Blocker Heart Attack Trial,38 only 34% of patients
in the USA were treated at discharge, and even fewer had
sustained adherence, according to hospital audit data.
Subsequent improved uptake required support from
national guidelines and inclusion in hospital accreditation
standards.
The underuse of β blockers for more than a decade after
publication of the original trial results, reinforces the fact
that underuse of any given health service can occur at
multiple stages along the continuum of care, even in
HICs: health systems can fail to provide sufficient access
to effective medication; physicians can fail to prescribe
effective treatment; and patients might not adhere to
effective treatment. It also highlights the important role
of health system processes in addressing underuse
through mechanisms such as quality improv­ement and
accreditation processes to drive behavioural change.
Slow, inconsistent, or stalled uptake by clinicians
appears to be the standard rather than the exception, but
with considerable variation across interventions. After
angioplasty for the treatment of coronary artery disease
was presented at an American Heart Assocation meeting
in 1977, widespread adoption occurred in less than
a decade in the USA and many other HICs. Subsequent
evidence that transradial angioplasty reduces compli­cations
compared with the transfemoral technique has not led to
comparably rapid uptake.39 Some of the reasons for faster
adoption, such as testability, ease of learning, relative
advantage, and compatibility with the pre-existing
system, were documented in the 1950s by Rogers in his
seminal work on the diffusion of innovations;40 however,
these patterns do not always hold true for the uptake of
medical interventions.
Underuse of a given effective intervention, even when
affordable, is often greater in lower-income countries
than in high-income countries, but not always. For
example, the use of antenatal corticosteroids for preterm
delivery (panel 1) varies considerably across countries.
A recent survey of 29 countries8 found that use ranges
from 16% to over 90% (figure 4). While use appears to be
higher in HICs, some LMICs, such as Palestine and
Peru, have good uptake, whereas Japan and Brazil have
low uptakes. However, a 2015 antenatal corticosteroid
cluster-randomised trial,41 which found an increase
in neonatal deaths from antenatal corticosteroids, has
suggested that transfer and scaling up of interventions
requires caution, and sometimes additional evidence.
Whether this increase arose as a result of unreliable
dating of gestational age, increased sepsis, or other

www.thelancet.com Vol 390 July 8, 2017 173

 Series

(8·8%, 9·7%, 5·2%, and 3·3%, respectively), and

Overall
Afghanistan decreased with reduction of country economic status
Congo (p for trend <0·0001 for every drug type).43
Nepal
Niger The causes of non-adherence can be complex. Building
Angola on our previous example, underuse of warfarin in
Uganda patients with NVAF at high risk of stroke is common,
Brazil
Nigeria with less than 60% of people receiving optimum
Qatar treatment.34 As stated earlier, these care gaps may be in
Kenya
Ecuador part due to the physician values and concerns, but can
Thailand also result from poor assessment of patient values and
Philippines
concerns. In a study44 of the maximum increased risk of
Country

Vietnam
Mexico bleeding (threshold risk) that people would tolerate to
Lebanon achieve a reduction of three strokes in 100 patients, the
Cambodia
Japan median threshold risk for both patients and physicians
Pakistan was ten additional bleeds, but with wider variability in
Sri Lanka
China
patients than clinicians (patient range 0–100, physician
India range 0–50): one cluster of patients and physicians would
Mongolia tolerate fewer than ten bleeds and another cluster of
Paraguay
Nicaragua patients, but not physicians, would accept more than 35.
Argentina This example illustrates that when patients are poorly
Peru
Palestine
informed of treatment choices and potential outcomes,
Jordan or their preference has been ignored or not elicited, the
0 25 50 75 100 right treatment might not be delivered.
Receiving corticosteroids for preterm delivery (%)

Figure 4: Use of antenatal corticosteroids for preterm delivery in 29 countries
Underuse of antenatal corticosteroids remains prevelant 40 years after the first randomised controlled trial.8
problems is uncertain, but illustrates that interventions
do not occur in isolation, but within a context of other
diagnostic and supportive treatments.
(D) Patient use and adherence
Patients not attending scheduled visits or not accepting
recommended care can occur as a result of barriers,
including distance, affordability, culture, stigma, language,
socio-economic status, and race. For example, in the
Chinese registry study discussed previously, in 30% of
non-use of warfarin cases, it was the patient who declined
anticoagulation.35 However, even when patients accept
treatment recommendations adherence can be poor,
hence diluting the effectiveness of a health-care system,
that ensures that the first three stages on the treatment
continuum do not pose a barrier to treatment. For
example, secondary prevention with drugs and lifestyle
changes following acute myocardial infarction has greatly
improved outcomes, but a recent retrospective cohort
analysis in the USA documented low adherence at
12 months after discharge for prescribed drugs: 66% of
patients were taking their β blockers, 63% angiotensin-
converting enzyme (ACE) inhibitors/angiotensin receptor
blockers (ARBs), and 66% statins.42 These findings are
echoed in a multicountry survey of patients with a
self-reported cardiovascular disease event in the past
four years, where use of preventive medication was
generally low. Adherence was highest in HICs (antiplatelet
drugs 62%, β blockers 40%, ACE inhibitors or ARBs 50%
and statins 66%), but much lower in low-income countries
Harms to patients and health systems
What is the extent of harm caused by underuse? The most
obvious and concerning harms are poor patient outcomes—
unrelieved symptoms, serious disability, and deaths,
including preventable maternal and perinatal deaths. Such
adverse outcomes have been documented in both LMICs
and HICs (figure 5), but there are also significant harms
related to non-clinical outcomes, such as financial burdens
for patients and families, spending precious remaining
time in a hospital instead of at home, loss of patient
autonomy, and diminished ability to participate in daily life.
Harms to patients
The substantial differences in life expectancy between
countries suggest likely underuse of effective prevention
and treatment, but precise quantification of the contribution
of underuse to population-based health statistics is difficult.
One study of declines in so-called amenable mortality—
which would be attributable to underuse—found that it
slowed for Americans younger than 65 years, relative to
their peers in Europe. For example, from 1999 to 2007,
amenable mortality rates in men fell by only 19% in the
USA compared with 37% in the UK, and among women,
the rates fell by 18% and 32%, respectively.46 Deaths from
circulatory conditions, such as cerebrovascular disease and
hypertension, were considered the main reason that
amenable death rates remained relatively high in the USA.46
The authors point out several limitations in trying to
estimate avoidable mortality, but suggest one reason might
be the poor access for people who are uninsured. For
example, insurance coverage reforms in Massachusetts
(2001–2005 compared with 2007–2010) resulted in a
significant decrease in all-cause mortality compared with

174 www.thelancet.com Vol 390 July 8, 2017

 Series

the control counties in other states (–2·9%; p=0·003, or an

A Global maternal deaths
absolute decrease of 8·2 deaths/100 000 adults): deaths 1200
from causes amenable to health care also significantly
decreased (–4·5%; p<0·001).47 The number needed to treat
was approximately 830 adults gaining health insurance to
1000
prevent one death per year. Similarly, a geographical
regression discon­ tinuity study in India found that

Maternal mortality per 100 000 live births (%)

government-funded health insurance for people below the
800
poverty line had a positive effect on access to care and
subsequently on health outcomes.48 Removal of financial
barriers is very likely to reduce underuse and improve
600
health outcomes. This and other countermeasures for
underuse (and overuse) will be discussed in greater detail
in the fourth paper in this Series.
Maternal mortality is largely avoidable, and hence 400
Africa
provides a clearer picture. Although maternal mortality SE Asia
has fallen globally by 47% between 1990 and 2010, the Global
East Med
Millenium Development Goal (a 75% reduction) was not 200
W Pacific
achieved by 2015. Of the estimated 287 000 maternal Americas
Europe
deaths in 2010, LMICs account for 99%, with the majority
in sub-Saharan Africa (162 000) and southern Asia (83 000). 0
1990 1995 2000 2005 2010 2015
The more than 100-fold differences in maternal mortality Year
between countries suggest that most of these deaths are
preventable, and figure 5 shows estimates of the potential B Maternal deaths in Pakistan
effect of better access to services in Pakistan. Pragmatic coverage 99% coverage Unavoidable deaths
Some changes in practice are demonstrably feasible at Total
low or no cost. In the Philippines, Maria Silvestre found
Miscellaneous
that poor newborn care, such as no delayed clamping,
was causing preventable morbidity and mortality. Maria Post-partum haemorrhage
Silverstre and colleagues developed a guideline and
Adverse outcome

training programme49—Unang Yakap (the first
embrace)—to overcome this, reducing admissions to the
neonatal intensive care unit (NICU), neonatal sepsis
rates, and maternal and newborn deaths in the 11 pilot
hospitals. This example shows the negative effect of
underuse of delayed clamping on both morbidity and
mortality, and the health system, which pays for
preventable NICU admissions.50
With constrained budgets, not all underused
interventions are affordable. Hence the Disease Control
Priorities in Developing Countries Report51 has
recommended four categories to describe the efficiency
of interventions: (1) neglected opportunities (low
coverage but high cost-effectiveness; (2) interventions to
scale back (high coverage but low cost-effectiveness;
(3) interventions for which scaling up is inefficient
(low coverage and low cost-effectiveness); and
(4) cost-effective interventions used widely (high coverage
and high cost-effectiveness). The first of these is most
relevant to underuse and the report highlights more than
25 low-cost opportunities that are neglected, which often
have a cost of less than $100 per disability-adjusted
life-year averted, such as: hygiene promotion for
diarrheal disease; training volunteer paramedics with
lay first responders; intermittent preventive malaria
treatment in pregnancy; insecticide-treated bednets;
acute management of myocardial infarction with aspirin
Anaemia
Infections
Hypertensive disorders
Obstruction labour
Abortion
Ante-partum haemorrhage
0 20 40 60 80 100
Women (%)
Figure 5: Adverse outcomes of underuse in both low-income and middle-income and high-income countries
(A) International variation in maternal death rate. (B) Causes and preventability of maternal deaths in Pakistan
from an improved range of maternal, newborn, and child health primary health-care services.45 SE=southeast.
W=western. Med=mediterranean.
and β blockers; and HIV/AIDS peer and education
programmes for high-risk groups.
Reducing underuse can apply to processes designed to
improve care. For example, by a stepwise process
improvement in the insertion of central lines in intensive
care units, Pronovost was able to reduce infections leading
to sepsis and death to zero.52 When these processes were
replicated across 103 intensive care units in Michigan, this
improvement saved 1500 lives and around $175 million
over an 18 month period, suggesting underuse of this
quality improvement process has resulted in considerable
mortality and cost. Similarly, the CRUSADE Quality
Improvement Initiative tracked and improved coronary

www.thelancet.com Vol 390 July 8, 2017 175

 Series
care.53 The failure to use such processes represents both
unnecessary loss of lives and wasted resources. This
example also illustrates a wider problem that the underuse
of effective interventions is not limited to clinicians and
patients; policy makers and managers also fail to
implement processes based on evidence.54–56
Harms to health systems
Underuse often represents a misallocation of resources:
opportunities to provide needed, effective, and cost-
effective care are often competing with less effective
services, which may be more heavily marketed and more
expensive. Moreover, what might represent underuse in
one country has to be considered in the proper context
in another, according to resources and priorities. For
example, the Department of Health in the Philippines
has invested heavily in newer, expensive vaccines such as
human papilloma virus, rotavirus, pneumococcal, and
dengue vaccines, despite the fact that they have not yet
achieved full coverage for more standard, cheaper
vaccines such as DPT, measles, mumps and rubella, and
polio, and consequently children are still dying of
measles, diphtheria, and tetanus.57
In many countries, Health Technology Assessment
processes have been established to control overuse, but
this has had some drawbacks: new, expensive, high
technology devices, services, and pharmaceuticals come
under scrutiny, because they are expensive, often have an
eager sponsor making the submission, and have an
enthusiastic and influential clinical workforce (such as
surgeons or specialists). Low-technology treatments
might have high value but lack these three dimensions
and thus avoid the re-imburser’s scrutiny.58
Conclusion
Underuse occurs at all stages along the care continuum:
from poor health-care access, to lack of availability, failure
of providers to deliver service, and failure of patients to
use it. Underuse also appears to occur across countries,
regardless of payment model or health system, and in
clinical settings ranging from rural clinics to tertiary
hospitals. Despite the fact that underuse is frequently
recognised as a problem around the world, obtaining
good estimates of its extent is hampered by a lack of
studies of many conditions and health services, the
complexity of the problem, and the paucity of population
monitoring. Furthermore, studies of the harms of
underuse are in particularly short supply. Although
global spending on health and medical research is about
$200 billion per year, only a small fraction is aimed at
better understanding and overcoming the barriers that
prevent better uptake of effective interventions, and
methods to make them affordable.
The estimates and examples of underuse in this paper
indicate that it remains a serious problem in both HICs
and LMICs. Underuse causes substantial harm to both
patients and health systems, and is deserving of greater
176 www.thelancet.com Vol 390 July 8, 2017
attention from the health care and research communities.
A much more systematic approach for identifying
important areas of underuse is needed if we are to address
this serious problem.
The global health community must focus its attention
and resourcing for health policy and health systems work
at each of the stages we have outlined. Subsequent papers
in this Series will look at the causes and drivers of
underuse (and overuse) and possible solutions, but
investment and action are urgently required.
Contributors
SB, VS, and PG drafted the outline; PG led the redrafting; all authors
contributed to sections and examples in the paper, provided substantial
revisions, and approved the final version of the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
Work for this paper was supported by The Commonwealth Fund,
a national, private foundation based in New York City that supports
independent research on health care issues and provides grants to
improve health-care practice and policy. The views presented here are
those of the authors and not necessarily those of The Commonwealth
Fund, its directors, officers, or staff.
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58 Jena AB, Stevens W, McWilliams JM. Turning evidence into practice
under payment reform: the new frontier of translational science.
J Gen Intern Med 2014; 29: 1542–45.
 Series

Right care 3
Drivers of poor medical care
Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug, Shannon Brownlee, John P A Ioannidis, Elliott S Fisher

Lancet 2017; 390: 178–90 The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate
Published Online an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor
January 8, 2017 care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and
http://dx.doi.org/10.1016/
S0140-6736(16)30947-3
uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional,
and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of
This is the third in a Series of
four papers about right care poor care in each domain.
See Comment pages 101, 102
and 105 Introduction Multiple drivers of poor care interact throughout this
Lown Institute, Brookline, MA, Papers 1 and 2 in this Series outline the scope of poor ecosystem. We aim to outline a navigational chart for
USA (V Saini MD, A G Elshaug PhD, care from both overuse and underuse of medical addressing this fundamental problem of modern health
S Brownlee MSc); Aragon services. care. Reducing poor care will require a well contextualised,
Agency for Research and
Development, Zaragoza, Spain
Drivers of poor care reside in three major multidimensional, and concerted effort by health-care
(S Garcia-Armesto MD); domains: money and finance; knowledge, bias, and professionals, policy makers, and the public. Previous
Aragon Health Sciences uncertainty; and power and human relationships. Drivers definitions of quality of care have focused on
Institute, Aragon, Spain operate in specific contexts and contribute to the overall evidence-based health outcomes of individuals and
(S Garcia-Armesto);
Ostbayerische Technische
quality and quantity of care delivered. These contexts are populations incor­ porating patient preferences.1 Our
Hochschule best considered as different levels in an ecosystem of conception of the right care extends this definition further
Regensburg, Fakultät care delivery: global; national, legal, regulatory, and by including the importance of stewardship in the
Angewandte Sozial-und
cultural; regional, institutional, and social; and the distribution of societal resources through what inherently
Gesundheitswissenschaften,
Regensburg, Germany individual locus of the doctor–patient relationship. is a political process.
Drivers at the global level affect multiple actors across all
societies—for example, the mass media and multinational
Key messages corporations. At national, regional, and local levels,
• The biomedical model of the past century has been valuable for some aspects of variation in legal and regulatory regimes, power
medicine and is a necessary, but not a sufficient, component for the proper care relationships among stakeholders, and cultural norms
of patients and traditions, act differentially. Social networks—of
• The biological, psychological, and social needs of patients and informed preferences patients and families on one side and professionals and
must define desirable outcomes and appropriateness of care delivery systems on the other—act as local mechanisms of
• Greed, competing interests, and poor information are universal drivers of poor care transmission of all drivers. Provider stakeholders, such as
that occur across all systems and settings professional societies, operate locally, nationally, and
• Inaccurate knowledge and information of all stakeholders regarding effective and increasingly, globally, to convey standards of practice, even
ineffective care is a key driver of poor care as they legitimate clinicians’ professional autonomy.
• The levers for knowledge dissemination and adoption of health technologies are too The creation and dissemination of knowledge occurs at
often distorted by a fascination with innovation, which is reinforced by vested interests various levels via multiple actors. However, care itself is
• Systemic factors, cognitive frameworks, and cultural influences, particularly regarding initiated at the individual level from the centre of the
health, health care, science, and technology, are important drivers of care and have to ecosystem, where up to 80% of health-care costs are
be understood to improve health-care decisions at all levels initiated.2 Here, the patient and the doctor sit, with their
• The way in which each health system is organised and financed, and how resources are own individual and social identity, cultural and cognitive
allocated towards facilities and workforce, allows each of these drivers to have more or biases, and the cumulative influence of the forces
less influence surrounding them. These individuals also bring their
• The substantial economic interests of the health-care industry and the alignment of experience, emotion, transference, and counter­transference
incentive structures within health services are major drivers of potentially biased to the encounter.3
knowledge generation and health-care delivery worldwide Numerous additional variables exist within this
• Failure to reinforce professional ethics and protect the therapeutic relationship from relationship, including the clinical calculation of benefits
financial concerns distorts medical care and harms, patient preferences, physician preferences,
• Regulatory capture, disempowerment of communities and citizens, and a political provider training and competence, available infrastructure,
aversion to priority setting all drive poor care financial incentives, trust and understanding between
Understanding these drivers and the various ways in which they act across systems patient and clinician, and the influences of others, both
provides opportunity to increase the social and individual value of care individually and through social networks. Clinical decision
making emerges from this complex interaction. In this

178 www.thelancet.com Vol 390 July 8, 2017

 Series

Series paper, we describe the major drivers of care and Integration across levels of care (D Klemperer MD); Health
how they operate. The degree of integration across levels of care is a key Division, Organisation for
Economic Co-operation and
system feature that influences the quality of care. Development, Paris, France
Money, finance, and organisation Many health-care systems’ financial flows promote (V Paris); Menzies Centre for
Health coverage, resource allocation, and the fragmentation: the poor coordination of services delivered Health Policy, School of Public
organisation of care delivery to any individual patient often leads to duplication of Health, Sydney Medical School,
University of Sydney, NSW,
Overuse and underuse of care exist in all types services (eg, imaging tests) and failure to deliver needed Australia (A G Elshaug);
of health-care systems.4–6 However, financing arrangements services (eg, preventive or palliative care).24,25 Department of Health Policy,
influence the relative strength of the various drivers and Havard T.H. Chan School of
how they contribute to poor care (figure 1). Economic incentives can drive poor care Public Health, Cambridge, MA,
USA (S Brownlee); The
Inadequate health coverage is a primary cause of poor Influence on clinicians’ behaviour Dartmouth Institute for Health
care. For example, people who are uninsured or Systems of payment influence the behaviour of health- Policy and Clinical Practice
underinsured often forego or are denied essential care care professionals.26,27 Fee-for-service or volume-based (E S Fisher MD); Stanford
because of an inability to pay.6,7 Decisions about what payments encourage the provision of covered services Prevention Research Center,
Department of Medicine, and
is covered and accountability for appropriate clinical in contrast to capitation or salaries for health Department of Health Research
decisions influence health-care delivery.7,8 When coverage professionals that do not. Standards of professionalism and Policy, Stanford University
focuses on truly effective or cost-effective care, it can alone cannot ensure that services delivered serve School of Medicine
(J P A Ioannidis MD) and
encourage the use of appropriate care, but coverage patients’ interests.26
Department of Statistics,
decisions are a blunt instrument that have broad effects Physicians routinely act in conformity with their Stanford University School of
and lack precision, so cannot alone prevent poor care.9,10 financial interests. Under fee-for-service payment, many Humanities and Sciences and
specialties deliver higher volumes of services, distorted Meta-Research Innovation
Center at Stanford
Financing and configuration of health systems referral rates, and lower prevention activity than with
(J P A Ioannidis), Stanford
The financing and configuration of health systems vary fixed payment schemes, such as, capitation and salary.28 University, Stanford, CA, USA;
widely and are key drivers of care. At one extreme, Moreover, physicians react to fee reductions by increasing and Geisel School of Medicine
market-based systems rely on private insurers and their activity and have incentives to induce demand—ie, at Dartmouth, Hanover, NH,
USA (E S Fisher)
self-employed providers, with public intervention limited
to consumer protection and helping people at high risk
Money, finance, and organisation
of catastrophic illness or those with a low-income gain
coverage.8,11 At the other end are government-led schemes
whereby entire populations are entitled to uniform Global

health coverage and salaried providers deliver care.12,13

Trade agreements Medical industrial complex
When health-care spending is publicly funded,
governments often exert control over expenditures, but
few distribute resources uniformly across regions or National
populations according to health needs. When they exist,
Resource Innovation tailored
allocation formulas usually combine crude indicators of constraints by commercial Insurance
Providers’
health (eg, age, sex, prevalence of disability or mental payment interests coverage
disorders) with socioeconomic indicators of need schemes
Private Public
(deprivation indices). Matching of needs and capacity is a
continual concern.14 Regional
In both private and publicly financed systems,
Fragmentation Mismatch between
misallocation of resources, including the health allocated resources and
Infrastructure
workforce, can lead to both overuse and underuse.8,15 For and workforce population needs
example, a high density of either general practitioners capacity
or specialists leads to an increased number of visits,
often initiated by physicians.16,17 Similarly, a high density Local
of intensive care unit beds is associated with increased
rates of admission.18 By contrast, low availability of Weak primary care Discontinuity and
redundancy of care
primary care professionals can lead to underuse of
essential services and increased hospital admissions
and specialty care.19,20 In systems in which providers
influence investment in capacity (eg, hospital beds per
capita), especially if they have the ability to retain
Care decision
operating surplus, there is often overinvestment
in high-margin revenue-enhancing capacity (eg,
cath­eter­
isation laboratories), and underinvestment in Figure 1: Money, finance, and organisation affect health-care decisions at global, national, regional,
less profitable services (eg, palliative care).21–23 and local levels

www.thelancet.com Vol 390 July 8, 2017 179

 Series
Correspondence to:
Dr Vikas Saini, Lown Institute,
Brookline, MA 02446, USA
vsaini@lowninstitute.org
Knowledge
Absence of
evidence
Clinical training adoption curves
paradigms
Figure 2: Production and dissemination of knowledge affects health-care decisions at global, national,
regional, and local levels
180 www.thelancet.com Vol 390 July 8, 2017
to provide services that a fully informed patient would DRG payments led to increases in the provision of
not choose.17,29 cataract surgery and endoscopies, which were profitable
Pay-for-performance schemes have been proposed to for hospitals.38 In contrast, incentives for provision of
encourage evidence-based and preventive services alternatives to conventional hospital admission seem to
through add-on payments linked to specific targets.30 be on the rise following the financial crisis.39 Thus, price
However, effects of these schemes on the quality of care setting, permitted profit margins, and the appropriateness
are inconsistent,31 and they can paradoxically encourage of fee or reimbursement schedules are all key elements
overprovision of unnecessary services and underprovision to promote the right levels of care. These elements are
of needed services.32 Another economic incentive that often hidden from public scrutiny.40
influences doctors’ behaviour is ownership of ancillary
services facilities, which encourages overuse.33,34 Patients’ behaviour
Patients’ behaviour also responds to economic factors.
Influence on hospital behaviour Insurance enables the use of medical services; although,
Payment per day to hospitals encourages long lengths of how much it increases use beyond necessary care is not
stay, and potentially, higher volumes of inpatient care;35 clear. The theoretical risk of abuse has generally been
conversely, hospitals under global budgets produce lower addressed by private health insurers through user
volumes of care, which can lead to underuse and long charges or copayments—which are much less common
waiting times.36,37 Many countries have switched to in national health services. The introduction of
payment per case (known as diagnosis-related group copayments reduces inappropriate use of services
[DRG]). Depending on the overall context and the initial (ie, overuse).41,42 However, it also reduces use of necessary
payment method, this change increased (Australia, or essential services.9,43 Some studies show that increased
Denmark, England, France, Norway, Spain) or decreased cost-sharing on pharmaceuticals decreases compliance
(USA) service activity.36 and increases use of non-pharmalogical interventions,
Payments per case can incentivise hospitals to such as potentially avoidable hospital admissions due to
encourage more admissions if the price for that particular worsening of the condition, or emergency visits to obtain
DRG is set high relative to production costs.36 In France, medication in acute episodes in patients with chronic
diseases.9,44 Copayments reduce demand for preventive
services, because people tend to overestimate present
costs and underestimate future health benefits.45
Global
Universal Mass media
cognitive amplification Commercial interests
biases and distortion Corrupted Commercial interests shape the availability and use of
medical novel therapies. Pharmaceutical and medical devices
research
National industries target their research, development, and
marketing strategies towards the most profitable
Flawed diffusion Public research opportunities, typically the health problems of large
funding Medical
education populations that can pay, or rare life-threatening
curricula conditions affecting small numbers of patients in wealthy
countries,46–49 while often neglecting the health needs
Regional of poor populations.50–52 This unequal distribution of
purchasing power can embed a long-term structural
Cultural bias stream of distorted care.53,54
Research activities, measured in randomised controlled
trials, do not reflect the worldwide research needs as
defined by the global burden of disease.55 Industry focus
Local on marketable medical interventions, coupled with the
regulatory regime of a country and its health-care
Flawed forms of Attitude towards resources, constrain the therapeutics available to
decision making risks and preferences practitioners and patients, thereby exerting a considerable
influence on the amount and type of care provided. After
regulatory approvals, industry uses a range of strategies
to sell products and expand markets and market share.54,56
Such marketing efforts are often successful at increasing
Care decision
sales, but might not improve the health of either
individual patients or populations.54,56
Intellectual property regimes legitimise monopoly
pricing based on the need to encourage further

investments in research and development, while holding
out the promise of competition after patents expire.57
Meanwhile, the rising prices enabled by such patents can
strain budgets and force administrative or other forms of
rationing, which can drive underuse.58
By contrast, subsidies can accelerate adoption.59 How
price is determined in health-care innovation varies widely,
and is partly a policy choice.60,61 In many countries, prices
are regulated or determined by the largest purchaser,
usually the national government. In countries with
market-based pricing, where the seller has a monopoly
and buyers have minimal power, often little direct
association exists between price and value to patients;
neither governments nor private health plans appear able
to effectively negotiate a price, especially in the face of a
political mobilisation of patients. Describing these prices
as market-based is thus problematic. Sofosbuvir62 and
biologic cancer drugs63 are recent examples of this point.
In reality, because truly novel compounds are rare and
new drugs get approved in most countries without proof
of superiority to incumbents, companies can compete
for revenue share through marketing campaigns for
pre-existing compounds more easily than they can invent
new ones.64 Hurdles for the approval of medical devices
are lower than for pharmaceuticals, raising both safety
and efficacy concerns.65–67
Knowledge, beliefs, assumptions, bias,
and uncertainty
Thinking frameworks influence decision making
Thinking frameworks are determined by social and
cultural contexts and the interplay between cognitive,
emotional, and motivational thought processes.68
Thinking frameworks lead to beliefs that strongly
influence cognition, judgments, and decisions, and exert
a powerful influence on decision making in health care.
More is better, new is better, more expensive is better,
and technology is good, are examples of deep and often
intuitive beliefs about the benefit of interventions. These
beliefs affect many areas: research agendas, product
development, market opportunities, and regulatory
control or tolerance (for example, an intracerebral stent
system was provisionally approved because of biological
plausibility, but without adequate safety data).69,70
Together, these beliefs affect patients, their families,
clinicians, administrators, policy makers, and political
leaders, often leading to overestimation of benefit and
underestimation of harm (figure 2).71,72
Panel 1 lists patients’ and doctors’ beliefs that can drive
use of services. For example, many patients’ false belief
that chemotherapy can cure advanced cancer regularly
leads to overuse of chemotherapy,91 and some patients’
fears of surgery will lead them to decline potentially
beneficial procedures if not well informed, leading to
underuse.92
Physicians’ awareness of evidence and attitudes
towards guidelines have been identified as shaping
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Series
Panel 1: Beliefs and behaviours of patients and clinicians
that contribute to poor decision making
Patients
• Medicine is based strictly on science73–76
• Testing, especially high-tech testing, is accurate (poor
understanding of error rates and other limits in tests and
treatments)73,74,77
• Unquestioning trust in the doctor’s expertise78
• Fear of offending clinician by asking questions
• My neighbour, niece, coworker had this done, and they
had a good outcome79
• Demand induced by providers and other commercial
actors in the health-care industry
• More care is better care, especially in a system without a
longitudinal relationship, whereby the measure of caring
is by doing rather than by being present
• Misplaced assumptions and mistrust about financial
motives of providers80
• Anxiety about uncertainty and adverse outcomes81
Clinicians
• Evidence contradicts training or practice experience82,83
• Physician innumeracy84
• Over-reliance on pathophysiological and anatomical
reasoning and faith in surrogate outcomes73
• A so-called better to know bias that might not be
warranted85
• Improper weighing of relative risk versus absolute risk86,87
• Regret of omission overriding regret of commission86
• Therapeutic or technological enthusiasm84,88–90
• Recent adverse outcome, rear-view mirror bias
(a manifestation of the affect heuristic)86
behaviour. Practitioners might disagree with guidelines,
especially if evidence seems to contradict their
preconceptions and experiences.93 Such conflicts could
be a result of imprinting during training,60,83,94 which
has a mixture of cognitive and emotional effects (the
so-called hidden curriculum).
Heuristics shape thinking frameworks
Beyond these general frameworks, psychological
research has empirically identified strategies of cognition,
termed heuristics, that influence decisions in situations
of uncertainty.92,95,96
Because rapid, high-volume clinical decision making is
part of the everyday routine of physicians, and requires
combining and synthesising diverse data and performing
complex trade-offs between benefits and risks,97 such
heuristics are probably important. These mostly
unconscious mental shortcuts often lead to accurate
results, but can also be dysfunctional and lead to skewed
judgments.98
Several heuristics and biases have been described and
investigated, but few studies have been done in medicine;
a 2015 systematic review found 19 different types of
 Series
Panel 2: Examples of heuristics and biases in medicine
Availability heuristic
Relates to judgment on the basis of the ease with which
information, such as a diagnosis, come to mind, rather than
the validity or relevance of the information79,86,99—eg, thoracic
pain in a 60-year-old patient interpreted as a thoracic spine
problem by the orthopaedist and a heart problem by the
cardiologist.
Representativeness heuristic
Describes the judgment of a clinical situation79 on the basis of
the similarity to a category, (eg, chest pain in a 34 year old),
without regard to the underlying base-rate of myocardial
infarction, thereby missing causes that could be more likely.
Similarly, clinicians might overestimate the benefit of cancer
screening in people aged 35–55 years, unaware of the low
incidence of cancer in this age group.99,100
Confirmation bias
A tendency to search primarily for confirmatory information
and generally giving more weight to information that
confirms one’s expectations than to contradictory
information.86 Confirmation bias is evident when authors
with a conflict of interest relating to a certain drug judge this
drug more favourably than authors without a conflict of
interest. Tamiflu and rosiglitazone are recent examples.101,102
Commission and omission bias
Omission bias results from the belief that harmful
intervention is worse than inaction, whereas commission bias
results from the belief that prevention of harm requires active
intervention.86,103–105
cognitive heuristics and biases in clinical decision
making, four of which are presented in panel 2.86
Common assumptions of modern medical culture
Health care is assumed to be the main determinant of
health. Although the contribution of health care to life
expectancy and quality of life cannot be quantified
precisely, improvements in living conditions and public
health interventions have contributed more than medical
intervention to the gains in health in the 20th century. Less
than 20% of the health status of populations is attributable
to health-care delivery systems.106–112 However, assumptions
to the contrary inflate expectations about health care and
create market opportunities and political support for
expansion of services, which potentially distorts the
balance between health-care and social spending.89,108,109
Dominance of the biomedical model
Modern medicine has successfully applied biomedical
science through a model that construes disease as the
disruption or deviation of biological variables. This
model shapes conceptions of diagnosis,73 treatment, and
prevention as ever more detailed understanding of ever
smaller biological units,113,114 which is one aspect of the
182 www.thelancet.com Vol 390 July 8, 2017
proliferation of therapeutic options available for the care
of patients, eg, with stable coronary disease.115
This model of disease has resulted in remarkable
successes (antibiotics, vaccines, organ transplantation,
heart surgery, cures for some cancers) as well as expensive,
marginally useful, or even useless interventions.116 The
prestige earned by the successes of this model elicits a
presumption of rigorous scientific efficacy from the
public.73,117 This illusion can drive suboptimal care when
reductionist thinking, sometimes coupled with the
commercial imperatives of product development, triggers
a search for single optimum solutions that yield
questionable benefits at increasing expense.118
This focus on deviations from biological norms instead
of patients’ needs is one of many factors that underpin
the widespread lack of patient involvement in decisions
and treatment goals.72,119 Such a focus can lead to the
neglect of patients’ cognitive and emotional needs,73
preferences,120,121 underuse of counselling and behavioural
therapies, and neglect of social and public health
strategies for disease prevention.108–110 Medical care—a
visit to a physician, a day in hospital, or a surgical
procedure—comes to be seen as an intrinsic good in itself
rather than a means to help individuals achieve the goals
important to them.122–124 Failure to honour such goals can
result in overuse of disease-focused treatments at the end
of life, such as chemotherapy in advanced cancer, and
stenting in stable coronary heart disease.119,122,125–127
The isolated clinical relationship
The isolated clinical relationship is assumed to be the
sole driver of care, which ignores the effects of system
configuration. This scenario can drive underuse through
failure to adopt systems of reliability of care (such as
reminders or checklists) or through lack of staff support.
Patient care is further degraded when comprehensive
primary care is weak, coordination is poor, and systems
are fragmented.25 Efforts to ensure the right care are
usually left to practitioners and their professional
societies. Specialty societies elaborate treatment protocols
for diseases of their isolated organ system, while ignoring
the eventual role played by other specialists in meeting
patients’ needs. Thus it is common for each specialist to
add drugs or interventions to a long list; although each
might seem sensible in isolation, as a combination they
can be irrational, if not harmful, for a patient to follow.
Flawed production and dissemination of knowledge:
the price of innovation
A core driver of both overuse and underuse is ignorance
of the evidence and its failure to change practice.120 The
impact of evidence-based medicine campaigns has been
hindered by the considerable volume of information
production, and dilution of good studies by bad ones.
Contradictory results increase confusion.74,121
Although medical science research is presumed to ask
questions and examine areas of interest that matter to

patients and citizens, 85% of the global investment in
biomedical research—US$240 billion in 2010—is wasted
on research that fails in that mission.74,121,128 Many trials are
underpowered; study endpoints chosen by professionals
often are of low priority for patients; questions of
functional, social, and emotional wellbeing, adverse
reactions, and long-term outcomes are disregarded; and
academia rewards short-term successes and newsworthy
results at the expense of results that are meaningful to
health.74 Industry-sponsored trials might ask questions
that are of little or no clinical value, or that are destined to
yield results that are favourable to the sponsor’s
product.75,129,130 These tendencies naturally lead researchers
and industry to seek widened denominators (so-called
indication creep) for tests or treatments proven effective
in one disorder.
Such flawed knowledge can increase adoption rates of
new practices beyond the factors such as relative advantage,
compatibility with existing systems, and ease of learning
that were documented by Rogers131 in the 1950s; when
coupled to revenue opportunities for the relevant actors
(industry, physicians, hospitals), adoption accelerates, no
matter how meaningless to patient outcomes, whereas
important research conclusions, such as the efficacy of
lumpectomy, sometimes diffuse slowly when the prospect
for revenue is absent. Thus, flawed science and incentives
can become powerful drivers of flawed adoption and of
resistance to the de-adoption of useless interventions.74,132–135
Society has a legitimate interest in health-care
innovation and technology development to the extent
they carry an implicit promise of improved wellbeing.
This outlook creates widespread public interest in the
latest medical developments.65,66,136 However, science and
technology are frequently at odds with one another.
Science essentially involves the ongoing refutation of
error73 whereas technology seeks a positive end, even if
imperfect, and expects gradual improvement through
product cycles.66 This tussle plays out on a daily basis in
the construction of narratives about health and medicine,
whether in the pages of medical journals or newspapers,
or on television and computer screens.76
Dissemination of knowledge depends on practitioners to
read, absorb, understand, and critique studies; to separate
high-quality and low-quality information; and to use this
approach to change practice patterns. Systematic reviews
and evidence-based guidelines are intended to help in this
process, but have been only marginally successful,
mitigated by the proliferation of guidelines from multiple
authorities, many contradictory, and often influenced
by conflicted stakeholders, sponsors, and authors.137–139
Nevertheless, guideline development remains an
important method of promoting the right care, provided
certain crucial criteria are met.140 A new effort to define
appropriate use criteria has emerged in several specialties,
implicitly acknowledging the inadequacy of outcomes of
previous guidelines.141 Efforts to include lay members on
guideline panels are in their infancy.142
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An additional issue in knowledge dissemination is
the growing popularity of web-based searches, online
decision-support tools, and social media advertising.
These techniques not only affect patient knowledge
and alter practice patterns in new and unpredictable
ways that offer great opportunity, but also warrant
considerable scrutiny. Such methods have the potential
to substantially amplify both knowledge and errors in
decision making.
Power and human relationships
Strength or weakness of the therapeutic relationship
At the centre of the ecosystem is the patient–clinician
relationship at the point of care. The quality of that
relationship is a central element of the clinical encounter
and an independent driver of the quality of care (panel 3).153
A poor relationship can drive both overuse and underuse.
Adherence to proven, cost-effective therapy, although low
in most studies of patient behaviour, is highly dependent
on the relationship.154–156 In the absence of mutual respect
and trust, an inadequate history can facilitate suboptimal
or even harmful treatment157 (figure 3).
A mismatch in the worldview of the patient and
clinician can cause problems.144 For example, young
people might not have the accumulated life experience to
understand the reality of unintended harms, or they
might allocate the value of quantity versus quality of life
very differently: thus, a young clinician with an older
patient could have very different assessments of risk and
value. A patient with a low income could realistically
have far greater concerns for the economic trade-offs of a
course of action than would the well-to-do prescribing
clinician. Results can be detrimental for both patients
and physicians when trust is eroded.158
Collectively, most health-care systems have failed to
optimise these factors, resulting in dissatisfaction
among both professionals and the public that has led
Panel 3: Factors in the therapeutic relationship known to
affect the quality of interaction and care
• Imbalances of power or trust can prevent shared decision
making.143
• Providers do not have time to convey complex
information in an understandable format, which
precludes mutually respectful decision making and
promotes a transactional culture.144
• Race, class, or other distinctions can lead to selective
offering of tests and treatments, unrelated to insurance
coverage or ability to pay.108,109,145
• Barriers including education, language, and cultural
mismatches between providers and patients.109,146–49
Increasingly common with global migrations across
national borders, these barriers also occur with internal
migrations in low-income and middle-income countries
in the midst of the epidemiological transition.150–152
 Series

Power Poor decision quality also drives both underuse and

overuse:165 randomised trials of shared decision-making
Global aids consistently find that, on average, 20% of elective
procedures would be unwanted if patients had
Medical industrial complex Mass media unhurried access to understandable, relevant clinical
information.166–168
National
Contest for political control
Corruption Fear of Regulatory regime
Health and health care represent areas of contest for
of ethics litigation political control. Care delivery is the net result of the
Delivery system
Professional configuration relative power of various stakeholders to influence the
bodies
process of decision making in the doctor–patient
Regional relationship.
Professional societies, academic medical centres,
Excessive or inadequate Varying stakeholder commercial interests, patient advocates, and the scientific
political mobilisation power relationships
and mass media all shape the way citizens view health
of demand
Local culture and care. They do so by creating and reinforcing powerful
socioeconomics
categories of meaning, such as professional autonomy,
self-regulation, innovation, science, value, individual
Local patients’ right to best care, while remaining silent on
opportunity costs or marginal benefits and using loose
Patient Trust
Doctor Fear definitions of life-saving treatments.65,73,74,76,144,169 For
Public Information example, the routine labelling of new technologies as
participation asymmetry innovation tags positive feelings and expectations to the
product and distracts from the fact that the true
benefit–risk profile is often unknown at the time of market
Care decision introduction and often remains unknown long thereafter.76
The mass media convey these messages in the pursuit
of their own interests (expanding the audience for their
Figure 3: Distribution of social and political power affects health-care decisions at global, national, regional, sponsors).170 All actors then develop messaging efforts to
and local levels
defend their self-interest in the process of clinical
decision making.142,160,171
to the tremendous growth of so-called concierge Stakeholders with sufficient economic capital can use
medicine worldwide as a private sector solution to a that ability to financially support and influence others,
clear human need. and reinforce terms most favourable to their interests.
This contest occurs primarily in the process of
Flawed decision making establishing consensus on what represents the best
The involvement of patients in treatment decisions is an scientific evidence. Regulatory and government agencies
ethical imperative that might be desired,159,160 but the then hold, in theory, the power of compulsion, acting as
ability of practitioners to implement this step is still principal agents of citizens and the common good.
limited by time, their own resistance to changing power However, selection of national policy leaders in health
dynamics, and systemic constraints.144,161 care is itself subject to the competing demands of
Ideally, the consent of the patient is obtained after stakeholders—ie, industry, hospitals, professional
informing, explaining, deliberating, and considering the societies, health unions, and the general public—and
potential benefits and harms of various treatment once in positions of public power, they are influenced by
choices.162 If more than one option is available, a preference other self-interested actors. For example, large hospital
diagnosis, which incorporates the patient’s values, has to systems and pharmaceutical and device companies often
be made.120 In reality, patients are rarely involved in a capture regulators:172–174 a career in health care at the
shared decision-making process, even when the procedure highest positions might entail switching from one side of
in question is elective; often physicians act according to the table to the other. These personal relationships that
what they consider the patient’s interest to be.72,123,160,163 This naturally develop can advance private interests without
scenario leaves ample space within which self-interested coercion or bribery.175
motives can influence decisions, however unconsciously,
and subsequently overuse or underuse can result.160,164 Political mobilisation and demand for care
Patients’ sense of mutuality in decision making can Excessive or inadequate political mobilisation can
drive both underuse and overuse. Poor decision quality increase or decrease demand for care and thwart attempts
reduces subsequent adherence to treatment plans.165 to achieve the right care. Certain sectors, ideas, and

184 www.thelancet.com Vol 390 July 8, 2017


messages can yield inordinate influence, particularly
when they coincide with industry interests. Others that
have fewer resources, such as public health institutions
or advocates for addressing the social determinants of
health, typically have a smaller voice and less power.176,177
Because political and economic power are closely linked,
effective mobilisation often depends on financial ability
to influence mass media, affecting cultural norms and
public policy.178–181 Together, these processes drive both
overuse of some services and underuse of others.178 For
example, mobilisation can influence regulatory and
pricing negotiations, when companies fund patient
groups that push to accelerate the availability of drugs
unapproved for the market,182 or when patient platforms
are created ad hoc during negotiations with authorities to
support inclusion of a drug in insurance benefits
(hepatitis C and sofosbuvir in Spain).62
Where private insurance companies exist, they have
enormous potential power within this ecosystem. In
theory, these companies have an interest in reducing
costs in the short term, potentially curbing overuse,
but driving underuse. In the long term, their incomes
rise with increasing health-care costs because their
revenues are a percentage of the total premium, and
their interest in curbing waste is therefore lessened.
Moreover, like all stakeholders, the behaviours of
private insurance companies are subject to the
distribution of power in the system— for example, the
ability of pharmaceutical companies to overcome
insurers’ imposition of copayments through patient
assistance programmes.183
Similarly, other actors in the health-care sector
maintain their own political mobilisation by creating
alliances with key opinion leaders,184 medical specialty
societies, and patient groups, while participating in
defining standards of care, widening definitions of
diseases,185 and creating new disease labels.186–189
In some countries (eg, New Zealand, USA) marketing
involves direct-to-consumer advertising.190,191 This approach
encourages consumers to demand drugs and other
medical products by increasing awareness (and concerns)
about diseases—examples being erectile dysfunction
(sildenafil), baldness (finasteride),186 blood clotting
(enoxaparin),192 and atrial fibrillation (dabigatran etexilat).193
In countries where direct-to-consumer advertising is
not allowed, companies sometimes promote new drugs
through disease-awareness-raising campaigns, which are
alliances between industry and consumer groups.194
For example, self-help groups that are sponsored by
pharmaceutical companies are associated with the
uncritical support of drugs such as celecoxib, rofecoxib,
and donepezil.195
These campaigns often inflate the prevalence of
diseases, such as social anxiety disorder,196 restless leg
syndrome,197 and female sexual dysfunction;198 increase
public fear of illness; and thus increase markets for
manufacturers.199
www.thelancet.com Vol 390 July 8, 2017 185
Series
Professional societies and other mediators
Professional societies, which have a privileged status in
most countries, play a key role in defining disease,
expanding definitions of disease, and defining
appropriate treatment thresholds. These societies are
viewed as authoritative sources of scientific medical
judgment on the presumption that the public benefits,
even though they primarily serve the interests of their
members.200,201 This dual role of medical societies creates
conflicts of interest that can influence both overuse and
underuse. An example is a professional society writing
guidelines that advocate for a certain intervention on
the basis of expert opinion, against or without existing
evidence (eg, prostate cancer screening and treatment
in France).202
Interaction between professional bodies, industry,
and entrepreneurs is frequent and natural, because
new technologies must pass through a process of
validation and legitimation in which professional
bodies play a crucial role.200 However, such interaction
creates opportunities for additional potential conflicts
of interest, as relevant expertise is inevitably associated
with opportunities to enhance income of individual
members, sections, and the professional society
itself.64,184,189,200
Many medical specialty societies accept support from
industry and have become financially dependent to a
considerable degree. In many countries, continuing
medical education systems are funded largely by
industry,203 creating conflicts of interest that bias
educational content.204 Other effective means to influence
physicians’ practice are sales representatives, distribution
of drug samples, and journal advertising.205,206 These
tactics tend to promote the use of more expensive brands
over generics, often directly subverting practice
guidelines and formulary policies.207 Total promotional
spending of the ten largest companies worldwide
amounted to $98 billion in 2013, presumably realising a
return on this investment.208
Given the outsized role professional societies can play
in regulatory approvals and reimbursement decisions,
whether directly or through informal networks of
influence, they have become central domains for all
actors seeking to influence medical practice.200 Peer
effects can amplify the wrong care, as doctors follow
leaders, doing what everybody does, even if misguided.189,209
Fear of litigation
Fear of litigation is a recognised driver of overuse.
A 2013 study210 shows that physicians’ fear of malpractice
lawsuits, independent of actual risks or of tort reform,
leads them to prescribe excessively advanced imaging
tests to patients with headaches and back pain. However,
estimates suggest only about 2% of care is attributable
to defensive medicine.211–213 Fear of litigation has not
yet become a driver of underuse; however, this is
theoretically possible.
 Series
Conclusion
The provision of care is initiated by decision making
within the doctor–patient relationship, but is
substantially influenced by the resources available for
health care within the society, its social and political
contract, the state of global and local scientific
knowledge, the configuration and capacity of the
delivery system, and financing mechanisms.8,22,74,214
Achievement of the right care requires an understanding
of and attentiveness to all these dimensions in the
development of policy choices for promotion of care
that is safe, effective, sensitive to personal preferences,
and just.
Although no one factor results in the provision of right
care, universal health coverage should be recognised as
essential at the population level. Each factor can be
deemed as equally necessary but equally insufficient by
itself. Reducing the role of greed by structuring financial
incentives to maximise true clinical benefits and social
value is key. Ensuring vigilance against error and bias,
broadening research aims, and a focus on meaningful
outcomes are key goals in the production of knowledge.
Therefore, re-addressing imbalances of knowledge and
power, not only within the clinician–patient relationship
but also within delivery systems, and more broadly in
society, is equally crucial. There are potentially many
levers to remedy poor care, but evidence of effectiveness
is very modest.
Finally, as biological creatures conscious of our
susceptibilty to injury, illness, and death, deep concerns
about health are universal. Public support is therefore
inevitably susceptible to manipulation for private gain.
Active public education, engagement, and empowerment
are crucial to ensure that the forces that shape health-care
delivery worldwide are truly focused on delivering the
right care.
Contributors
VS drafted the outline; all authors contributed to its redrafting. All authors
led a section of the manuscript and cross-contributed to sections and
examples throughout the paper, provided substantial revisions, and
approved the final version of the manuscript.
Declaration of interests
AGE receives salary support as the HCF Research Foundation
Professorial Research Fellow, and holds an Australian National Health
and Medical Research Council Sidney Sax Fellowship (ID 627061);
receives fees for consultancy and advisory board membership from
Cancer Australia, the Capital Markets Cooperative Research
Centre-Health Quality Program, NPS MedicineWise (facilitator of
Choosing Wisely Australia), and the Australian Commission on Safety
and Quality in Health Care. VS and SB receive support from the Lown
Institute and grants from the Commonwealth Fund and Robert Wood
Johnson Foundation. VP’s travel and accommodation costs to present
Organisation for Economic Co-operation and Development work on
pharmaceutical policies abroad have been occasionally covered by
pharmaceutical companies. ESF receives support from the Agency for
Health Care Research and Quality, the National Institutes of Health, the
Patient Centered Outcomes Research Institute, the Commonwealth
Fund and the Rx Foundation; receives fees for board membership from
the Institute for Healthcare Improvement, the Fannie E. Rippel
Foundation, and the Rx Foundation; received speaker fees from the
American College of Pathologists, Angiodynamics, Blue Cross Blue
186 www.thelancet.com Vol 390 July 8, 2017
Shield of South Carolina, Blue Cross Blue Shield of Louisiana, the
National Confederation of General Insurance (Argentina), Vizient, and
Signature Health. SG-A, JPAI, and DK declare no competing interests.
Acknowledgments
Work for this paper was supported by The Commonwealth Fund,
a national, private foundation based in New York City that supports
independent research on health-care issues and makes grants to
improve health-care practice and policy. The views presented here are
those of the authors and not necessarily those of The Commonwealth
Fund, its directors, officers, or staff. The authors are indebted to
Paul Glasziou for comments on the manuscript; Sarah Quddusi and
Yi Wang for assistance with references; and Paul Barker, Joseph Colucci,
and Carissa Fu for technical assistance.
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 Series

Right care 4
Levers for addressing medical underuse and overuse:
achieving high-value health care
Adam G Elshaug, Meredith B Rosenthal, John N Lavis, Shannon Brownlee, Harald Schmidt, Somil Nagpal, Peter Littlejohns, Divya Srivastava,
Sean Tunis, Vikas Saini

The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a Lancet 2017; 390: 191–202
complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has Published Online
considerable consequences for the health and wellbeing of billions of people around the world, remedying this January 8, 2017
http://dx.doi.org/10.1016/
problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right
S0140-6736(16)32586-7
care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an
This is the fourth in a Series of
understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work four papers about right care
during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and See Comment pages 101, 102,
clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority and 105
setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and Menzies Centre for Health
cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical Policy, School of Public Health,
underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health Sydney Medical School,
The University of Sydney,
and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to Sydney, NSW, Australia
local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move (Prof A G Elshaug PhD); Lown
beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. Institute, Brookline, MA, USA
In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal (Prof A G Elshaug,
S Brownlee MSc, V Saini MD);
methods to reset all other contexts and thereby enhance all other efforts to promote the right care.

Introduction
In this final paper in the Right Care Series on medical
underuse and overuse,1–3 we address two complementary
approaches to achieving the right care: so-called bottom-
up approaches, whereby patients, clinical professionals,
and system leaders take a proactive lead with little
interference from managerial authorities; and so-called
top-down policies, which have arisen as governments,
medical societies, or private third-party payers face the
challenge of improving the safety and quality of health
care amid growing pressure to control spending.4
Additionally, we suggest a more far-reaching perspective
than is typical of micro-meso level reform inititatives,
that includes a longer-term strategy for cultural change,
which has been scant to date.5 In 2014, Dickson and
colleagues6 outlined principles and strategies to
accelerate the scale-up of high-value interventions
known to be underused. We will not retrace those steps
in detail, and instead focus our attention on remedies
for overuse—a side of the equation that has received
less attention to date. Panel 1 contains definitions of key
terms used in this Series paper.
Setting the context: being clear about what we
want to achieve
Most countries across the economic development
spectrum aspire to high-performing, universally
accessible health-care systems. The shared challenge is
ensuring the right care is received by the right patients,
in the right setting, at the right time, at the right cost.
Key messages
• Because overuse and underuse are so deeply entrenched in contemporary medical care,
and because the harms are so considerable, efforts to remedy these issues are a moral
imperative and a political duty.
• Achievement of universal health-care coverage is a moral imperative and has been
adopted as a target under the UN Sustainable Development Goals in 2015. Focusing more
of the world’s attention towards redressing low-value care now becomes an urgent task.
The fundamental ethical, economic, and political challenge arising from poor care is that
as long as pooled funds are devoted to low-value care, the potential for health gain
elsewhere in the system is unnecessarily restricted.
• Although no perfect solutions exist for improving the quality of health care, health
technology assessment and other priority setting approaches have evolved to play a
central role in determining value. In this Series paper we investigate a wide range of
further interventions and policy levers that, if used appropriately, could lead to important
improvements in professional practice and patient outcomes.
• Appropriate involvement of patients, community, and civil society
organisations—supported through information sharing, evidence-based shared decision
making, and broad public engagement—could help improve the perceived and real
acceptability and legitimacy of determining the value of health-care interventions.
• Participation by these groups is essential for the success of any remedy to overuse or underuse.
• Clinical professionals and professional associations have a key role to play in championing
robust guideline development and implementation processes, filling evidence gaps with
quality clinical research, and leading or participating in efforts to shift from low-value to
high-value health care.
• Freeing the resources from low-value care creates new opportunities for redressing
underuse within the same budget envelope, by extending care to the non-covered,
reducing cost-related access barriers, and including services previously displaced by
lower-value resource allocations.

www.thelancet.com Vol 390 July 8, 2017 191

 Series
Department of Health Policy
and Management
(Prof M B Rosenthal PhD,
S Brownlee) and Department of
Global Health and Population
(Prof J N Lavis MD), Harvard T.H.
Chan School of Public Health,
Boston, MA, USA; McMaster
Health Forum, Centre for
Health Economics and Policy
Analysis, Department of Health
Evidence and Impact,
Department of Political Science,
McMaster University,
Hamilton, ON, Canada
(Prof J N Lavis); Department of
Medical Ethics and Health
Policy and Center for Health
Incentives and Behavioral
Economics, Perelman School of
Medicine, University of
Pennsylvania, Philadelphia, PA,
USA (H Schmidt PhD); The World
Bank, Phnom Penh, Cambodia
(S Nagpal MHA); Faculty of Life
Sciences and Medicine, King’s
College London, London, UK
(Prof P Littlejohns MD); LSE
Health, London School of
Economics and Political
Science, London, UK
(D Srivastava PhD); and Center
for Medical Technology Policy,
Baltimore, MD, USA
(S Tunis MD)
Correspondence to:
Prof Adam Elshaug, Menzies
Centre for Health Policy,
The University of Sydney,
Sydney, NSW 2006, Australia
elshaug@sydney.edu.au
192 www.thelancet.com Vol 390 July 8, 2017
Panel 1: Glossary of terms
Underuse
Failure to deliver a service that is highly likely to improve the
quality or quantity of life, that represents good value for
money, and that patients who were fully informed of its
potential benefits and harms would have wanted
Overuse
Provision of a service that is unlikely to increase the quality or
quantity of life, that poses more harm than benefit, or that
patients who were fully informed of its potential benefits and
harms would not have wanted
Right care
Care that is tailored for optimising health and wellbeing by
delivering what is needed, wanted, clinically effective,
affordable, equitable, and responsible in its use of resources
Low-value care
An intervention in which evidence suggests it confers no or
very little benefit for patients, or risk of harm exceeds
probable benefit, or, more broadly, the added costs of the
intervention do not provide proportional added benefits7
High-value care
An intervention in which evidence suggests it confers
benefit on patients, or probability of benefit exceeds
probable harm, or, more broadly, the added costs of the
intervention provide proportional added benefits relative
to alternatives
As the previous papers in this Series1–3 emphasise,
many health systems that provide near or universal
health-care coverage (UHC) face a dual challenge: the
underuse of high-value services, and the overuse of
no-value or low-value health-care services. With UHC
adopted as a target under the UN Sustainable Develop­
ment Goals in 2015, more of the world’s attention will
now focus on delivering the right care—not only in
countries making the first steps towards UHC, but also
in those that have been engaged in the process for
some time.
Interpretations of UHC vary. As previously reported,8
these interpretations include publicly funded and
provided universal, free, or affordable public health and
curative services;9 mixed funding or mixed provision of
services by the public and private sectors; UHC plans
that would reduce coverage content to minimum-
benefits packages or alternative systems of stratified
health-care delivery; and other UHC plan structures
that would primarily identify coverage with
market-based or private insurance-based decision
making. Further­ more, some of these definitions in
practice are not the same as health care for all, because
the aim is not necessarily to continually expand coverage
to enable care for everyone, and in fact can present
barriers to it.8 For example, some approaches, such as
tiers of differing benefit packages for rich and poor
individuals, can risk maintaining or worsening access
barriers as costs and corporate profits expand.
The WHO definition of UHC is the widely accepted
framework for understanding UHC: UHC is defined as
ensuring that all people have access to needed promotive,
preventive, curative, and rehabilitative health services, of
sufficient quality to be effective, while also ensuring that
people do not suffer financial hardship when paying for
these services.10 We believe this definition should be one
of the first guiding moral principles used when applying
the proper levers for achieving high-value health care.
Achieving optimum delivery of health care for the
optimum health of populations is hard to imagine
without considering this definition.
The fundamental ethical, economic, and political
challenge arising from this situation is that as long as
pooled funds are devoted to low-value care, the potential
for health gain elsewhere in the system is unnecessarily
restricted. This issue is the thrust of this Series paper. To
maximise these health gains, all health systems must
determine the efficacy of a given health service (can it
work in principle?), effectiveness (does it work in
practice?), technical efficiency (can it be produced at
lower resource cost?), cost-effectiveness (is it the least
expensive way to achieve an outcome, such as increasing
health-related quality of life?), and allocative efficiency
(is the outcome worth it compared to everything else that
we can do to improve wellbeing generally, for people who
use and pay for the intervention?).11 Focusing on care that
is clinically effective, and produced in a way that is
technically efficient and cost-effective, will make possible
both gains towards UHC (by freeing up resources) and
increase the gains achieved by investing health-care
resources where they can have the greatest effect.
Concentrating on allocative efficiency acknowledges that
wellbeing, rather than delivering some quantum of
health-care services, is the goal of health systems. Before
we discuss various potential remedies to underuse and
overuse, it is useful to outline a set of overarching
principles, which ought not be heavily contested, and
serve as a backdrop for the reform levers, as shown in
panel 2.
Learning from past experiences
Attempts to remedy underuse and overuse have been
ongoing since the mid-1970s with the Blue Cross Blue
Shield Medical Necessity Project to today’s Choosing
Wisely campaigns.14–18 Many of these programmes have
been plagued by barriers related to their acceptance and
implementation. Factors contributing to these barriers
range from a general lack of systematic priority setting
(eg, reliable, evidence-based administrative mechanisms
to identify and prioritise technologies and practices that
are both clinically effective and cost-effective19) to the
clinical, social, and political challenges of identifying
winners (services being underused) and losers (services
being overused). As we discussed in papers 1 and 31,3 of

this Series, one major driver of overuse is delivering a
service to more and more patients who lie outside of the
population for whom the service is clearly beneficial
(so-called indication creep). When that service is targeted
as being overused, clinicians might resist efforts to
restrict use if they believe the service might be removed
completely, rather than limited to the appropriate
populations or clinical indications.20 Although some
services should not be covered at all (eg, vertebroplasty21),
usually a better clinical definition of the patient
subgroups that will and will not benefit from any given
intervention is needed. This more nuanced understanding,
together with an acknowledgment of grey zones of
uncertainty, has bolstered support for contemporary
efforts at optimising appropriate care.22
Policy makers must choose their methods carefully so as
to arrive at a theoretical midpoint of appropriateness
between the tails of underuse and overuse. Levers that
target underuse can easily have the unintended
consequence of exacerbating overuse and vice-versa. For
example, more than a decade ago efforts were made in
numerous countries to increase testing for vitamin D
deficiency in primary care. In Australia, testing rapidly
gained popularity with a 4800% increase over 10 years,
much of which was clinically inappropriate and at a cost
that could have achieved much greater health benefits if
spent elsewhere. Furthermore, in 2014 Bhatia and
colleagues23 observed that efforts to decrease hospital
admission rates for patients with heart failure led to
increases in repeat emergency department visits and
hospital admissions after previous emergency depart­ment
discharge. Such examples show that the quest for
appropriate medical intensity, and the consequences of
overestimating or underestimating such intensity, are
ongoing challenges.
With these challenges and other considerations in mind,
we can begin to compile a list of potential remedies, noting
that no single lever is a universal remedy and many have
only a small (albeit growing) evidence base as to their
effectiveness.24 As we will highlight in this section,
achieving the right care will require levers targeted from
the patient level up to the government policy maker level,
and all require careful attention to contextual factors. A key
element of efforts to address overuse will be the prospective
evaluation of levers used, either before widespread
adoption or as part of a broad rollout. Cluster randomised
trials and interrupted times-series could assist with
understanding benefits and possible harms, cost-
effectiveness analysis could assist with appreciating value-
for-money considerations, process evaluations could assist
with understanding how and why levers achieve their goals
(and the implications for adaptations that can be made for
local contexts without jeopardising the effectiveness of
the strategy), and qualitative studies can assist with
understanding stakeholders’ views and experiences.
Constant monitoring and evaluation is equally important
to ensure that levers continue to achieve the desired goals,
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Series
Panel 2: Background principles that underpin reform levers
to remedy underuse and overuse
First principles:12
• Citizens of all countries value optimum wellbeing
• Universal health coverage that ensures effective and
affordable health care for all is one important means to
this end
• Health-care professionals are morally committed to
improving the health of their patients and they, alongside
system leaders and government policy makers, should be
morally committed to the health and broader wellbeing
of communities and nations
Collectively, health systems must:13
• Get the right—effective and cost-effective—care to the
right patients in the right setting at the right time
• Be affordable for patients and consumers, employers, and
tax payers
• Maximise the number of people with access to effective
and affordable health care that meets their needs
Specific components (individual services, devices, or
drugs) must:13
• Be safe (ie, not do harm)
• Be effective
• Be cost-effective
• Be valuable compared with alternative expenditures
• Be wanted by informed patients
In a transformed health system, patients can expect to:12
• Have access to effective and affordable care that meets
their needs
• Be informed and involved in choices about their care
• Be protected from commercial interests acting contrary
to their health needs
In a transformed health system, clinicians can expect to:12
• Have the time they need to care for their patients
• Make clinical judgments in the best interests of their
patients and of the broader community from which their
patients are drawn
• Feel supported by health, political, and legal systems
when they do so
both alone and in combination with other levers. Although
policy makers work under many institutional constraints,
face considerable interest-group pressure, and juggle
competing values, research evidence can and should be a
key input regarding decisions about whether to introduce,
scale-up, adapt, adjust, or stop using a lever.25
Levers through which high-value health care
could be achieved
Patients, community, and civil society organisations
Democratic engagement is both an intrinsic value and a
crucial lever for change. Patients and the wider public
should be involved in the effort to achieve the right care
 Series
Delivery arrangements
Matching allocation of supply-sensitive
resources (such as hospital beds and
health-care labour) to meet population
needs
Include inappropriate use
recommendations in CPGs
Development of appropriate-use criteria
with measurement
Audit and feedback
HIT and EHR
Education and other support for patients
and citizens regarding effective
self-management and SDM
Education and other supports for
professionals about SDM, guideline
implementation, and high-value care
delivery
Financial arrangements
Complete removal from coverage
schedules
Tighten or restrict indications associated
with coverage or reimbursement
Reduction in third party payment due to
technological advances
Partial reimbursement or coverage
(sits within value-based insurance
designs)
Reference coverage to rate of least costly
provider (meeting quality standard)
Reference coverage to rate of least costly
alternative for given condition
Sunset clauses (coverage with evidence
development)
194 www.thelancet.com Vol 390 July 8, 2017
Definition Examples, including evaluations
(system context most suited)
Certificates of need (wording varies between countries) are principled such that the construction of health-care 27
(All)
facilities (eg, new hospital beds) avoids excess capacity and supplier-induced demand for hospital-based
services. Most countries regulate the number of physicians and other health-care professionals, often through
subsidised training. Use of Six Sigma, the lean production method, and other methods to improve process
efficiency and reduce waste, allowing excess capacity to be cleared or allocated to reduce underuse.
Guideline developers are encouraged, when appropriate, to specify recommendations against the use of specific Do-not-dos28 (All)
practices, technologies, and pharmaceuticals (including for patient subgroups) when formulating guidance.
However, the evidence on which to base definite do and do-not-do recommendations is often scarce.
Evidence-based, consensus-driven development of appropriate-use criteria aid in articulating the patient 29–32
(All)
populations for whom any given practice is high-value vs low-value. These criteria assist clinicians at the point of
care (including via HITs); feed in to (and from) CPGs; facilitate SDM; direct indication-specific payment
parameters; and set the groundwork for measurement of high-value and low-value care in routinely
collected datasets.
Audit and feedback includes a summary of clinical performance of health care over a specified period of time 32,33
(All)
aimed at providing information to health professionals to allow them to assess and adjust performance.
A Cochrane systematic review reported a 4·3% increase in health-care professionals’ compliance with desired
practice, which could be as much as a 16% increase if baseline adherence is low and key design features are used.
Provider level reporting and feedback has shown success even when it was not public as seen in Canada in the
case of cardiac care revascularisation and harmonisation of clinical practice for caesarean section in Belgium.
HIT and EHR now include decision tools, clinical reminders, cost data, pharmacy records, and outpatient data— EHR flags (All)
all of which could be used to restrict the use of marginally effective medical interventions, ranging from
real-time flagging to improved auditing processes.
Many treatment choices patients face are preference sensitive in that each choice offers a different set of 36–38
(All)
potential benefits and harms.34,35 Excellence in communicating evidence-based benefits and harms in the SDM
process can reduce overdiagnosis, overtreatment, and undertreatment, and align informed patient preferences
with treatment choices.35 This process benefits from the use of patient decision aids.
Several high-quality reviews found that educational materials, educational meetings, educational outreach 25
(All)
visits, local opinion leaders, tailored interventions, audit and feedback, and computerised reminders had
beneficial effects on optimisation of clinical practice. The effect sizes found for each of these interventions are
similar, but have large variability, suggesting that the probable effects of interventions vary in relation to the
degree to which the causal mechanisms of action for the intervention address the specific barriers identified.
The variability also reinforces the importance of diagnosing the underlying cause of why low-value care is being
used or why high-value care is not being used and then, on the basis of the diagnosis, selecting from the array
of candidate strategies and iteratively refining, tailoring, and combining them in a way that maximises the
effect of efforts to optimise clinical practice.
For some technologies or practices, the evidence for safety and effectiveness is convincingly negative yet the Vertebroplasty39 (FFS; global budget)
practice persists. In these instances complete removal from funding schedules might be appropriate.
Often evidence mounts about the population subgroups who achieve the most, and least, benefit from Vitamin D tests; USPSTF age categories
particular technologies or practices. Reimbursement indications can be tightened to target those with the (FFS; global budget)
greatest capacity to benefit. Also, frequency rules have the effect of permitting a set number of tests or
treatments in a given timeframe.
In non-health markets, when technology delivers on its promise and becomes safer, faster, and easier to use, Cataract surgery40 (All)
the reduction in the cost of supply can drive the price down in response, provided the barriers to entry are few.
Such cost reduction rarely occurs in the health-care sector, but some examples are appearing.
For a practice known to deliver less value than its comparators (albeit still with some benefit in a subgroup of Arthroscopy for osteoarthritis (FFS)
individuals), the level of reimbursement or coverage can be tiered in accordance with the anticipated health
outcome.41 For example, patients could be required to pay the full cost of a low-value practice if they choose it
when a better-value alternative is available. Supplier-induced demand can raise ethical challenges here.
In the USA particularly, wide variation exists in the cost structures between provider institutions for the same VBID projects42 (FFS; diagnosis-related
or similar service. The payer agrees to cover the fee structure set by the least costly provider (whereby quality of groups)
outcome is matched). Clients are permitted to use more costly providers but must pay the difference.
For a given condition multiple treatment options might exist that deliver similar health outcomes (ie, one or USPSTF;43 equivalence or non-inferiority
more treatments is equivalent or non-inferior to a comparator) yet costs vary for each. Coverage can be driven cost minimalisation examples in
referenced to the least costly alternative. In cases whereby one treatment is deemed to be not inferior to the pharma44 (FFS)
main comparator, no basis exists in terms of health outcomes (safety profile included) to justify a higher price,
unless cost are offset as a result of a different method of administering the proposed treatment.
In cases whereby a health-care intervention has uncertain effectiveness, and insufficient evidence exists for 14,45
(All)
decision making (ie, substantial uncertainty exists) funding could be guaranteed only for a set time period and,
where appropriate, be conditional upon compulsory patient enrolment for evidence generation.
(Table continues on next page)
 Series

Definition Examples, including evaluations

(Continued from previous page)
Restricting later-line therapies from
creeping to earlier phases
Directed displacement or concurrent
specification: removal of an item from
funding when any new practice or
technology is first funded
Reimbursement only for guideline
adherence
Infrastructure for guideline production or
implementation and for HTA and HTRA
Global budget with pay-for-performance,
risk sharing, or bundled payments
Governance arrangements
Revising diagnostic criteria and thresholds As a countermeasure to overdiagnosis, which might include revisions to treatment recommendations based
Compulsory review of all technology,
however introduced
Restrict providers to centres of excellence
Stakeholder engagement
Changes to who has policy, organisational, Policy authority can be about who is covered, the services they receive, and the cost-sharing these individuals face. (All)
commercial, and professional authority to Organisational authority can be about whether accreditation is required and what it addresses, among other topics.
address underuse and overuse
(system context most suited)
Appropriate sequences of therapy are specified to ensure later-line treatments do not inappropriately move to Multiple treatment options for
earlier phases in the treatment algorithm. Achievable through FFS coverage levers and encouraged through obstructive sleep apnoea46 (All)
accountable care arrangements, which includes the reduction of unproven off-label usage.
Innovation met with exnovation: direct comparisons to be made between the incremental benefits associated Programme budgeting marginal analysis
with the new programme and the incremental benefits associated with those programmes that must be examples47 (All)
cancelled or reduced to generate the additional resources required. Such directed displacement is particularly
pertinent in fixed budget models of health care, whereby the concept of one in, one out can more readily be
considered explicitly. Opportunity cost is ubiquitous and thus exists in apparently uncapped systems, but the
feasibility of making and acting upon such direct comparisons remains to be shown.
Coverage is conditional upon clinicians adhering to appropriately endorsed practice guidelines. Any practice Pre-authorisation or post-hoc
deviation is only covered once judged before a panel of peers as acceptable deviation. Such an approach relies judgement (All)
on electronic systems for documentation of clinical activities.
Guidelines and HTA and HTRA are effectively public goods that can be used by all players in a health system to 48
(All)
address underuse and overuse of health care.
Global (eg, capitated) and bundled (eg, episodes of care) payments realign incentives away from volume (FFS) 49,50
(All)
towards quality of outcomes. Concomitant risk or profit sharing adds further incentives for providers to
achieve positive outcomes for their patients efficiently (ie, implementing high-value care).
Many cancers (All)
on risk profile of treatment vs no treatment, and prognosis.
Occasionally, technologies enter the system through atypical routes thus circumventing regular assessment Da Vinci robots14,45 (All)
entry processes (eg, charitable donations, manufacturer samples). Although initial outlays can be low, future
resource implications in training, maintenance, consumables, and staff time can be substantial. All
technologies to be introduced (by any avenue) should be subject to standard HTA review and decision
processes, ensuring they represent high value. Innovations in surgery might also fall under this rubric.
High-volume specialist providers might achieve superior outcomes to low-volume providers, which can be an Lung transplantation51 (All)
argument for restricting reimbursement to centres of excellence. Trading off equity of access is a consideration.
Stakeholder engagement can focus on creating the will to address underuse and overuse and the process can 52
(All)
give explicit voice to citizens, patients, and providers committed to achieving high-value health care. Different
members of the public or patient group representatives can be involved in practically any stage of HTA and
coverage decision processes—eg, the design of scoping documents; participation in evidence appraisal
committees as members or by providing information on living with conditions in question; or board
membership, contributing to the shaping of broader policy and underpinning value judgements.
Commercial authority can be about licensing or registering, pricing, marketing, selling, and purchasing products and
services. Professional authority can be about training, licensure, and continuing competence requirements.

CPGs=clinical practice guidelines. SDM=shared decision making. HIT=health information technologies. EHR=electronic health record. FFS=fee-for-service. USPSTF=US Preventive Services Task Force.
VBID=value-based insurance design. HTA=health technology assessment. HTRA=health technology reassessment.

Table: Policy leverage options available for system leaders and government policy maker

not only because they are both the recipients and ultimate
payers, but also because actively engaging these
individuals can increase legitimacy of efforts to determine
the relative value of various investments in health care,
from infrastructure to specific services that are covered.
Three principal methods of involving patients and the
public are as follows: shaping environments that help
reduce demand for low-value services through adequately
informed consumers; effective patient engagement in
clinical decision making to maximise value (especially
when care is preference sensitive); and public engage­
ment to improve priority setting at the highest policy level.
There are many reasons to involve patients and the
public in decision making. First, expectations or demands
from uninformed or mis­informed patients can result in
pressure on clinicians to provide low-value care. This
pressure is exacerbated by direct-to-consumer marketing.26
Additionally, hospitals frequently exaggerate the medical
utility of advertised services, such as proton beam therapy
for prostate cancer. The provision of evidence-based
information from trustworthy organisations that have no
conflicts of interest is especially crucial in such
settings (table).
Second, evidence-based shared decision making (SDM)
between patients and clinicians is important on both
clinical and ethical grounds. Many treatment choices
patients face are preference sensitive in that each choice
offers a different set of potential benefits and harms.34,35
Excellence in communicating evidence-based benefits
and harms in the SDM process can reduce overdiagnosis,
overtreatment, and undertreatment, and align informed
patient preferences with treatment choices.35 This process
benefits from the use of patient decision aids. A 2011
Cochrane review36,37,53 showed that well informed patients

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 Series
are less likely to choose to undergo surgery, in favour of
less invasive procedures, although this is not always the
case.54 However, even if less care is not always the result of
SDM, broader acceptance of remedies for overuse among
patients and the public is crucially important, given the
threat of rationing that often looms in the background of
limit-setting decisions: SDM can ensure that decisions are
made with, and not against patients.
Third, patient and public engagement is widely
regarded as useful at the policy level, although robust
evaluations about its benefits are rare.55 Many countries
increasingly involve patients and the public in health
technology assessment (HTA) and coverage decisions.
Commonly cited rationales focus on incorporating shared
values, improving the legitimacy or acceptability of policy,
and disseminating knowledge about decisions and
processes.55 However, despite considerable enthusiasm
among policy makers for public and patient involvement,
no consensus appears to exist about the priority among
these rationales, and there is no consensus about which
members of the public should be involved in which
processes, the weight these individuals should have in
influencing decisions, and how potential conflicts of
interests should be addressed.55 Although public and
patient involvement in decision making has clear
potential, evidence that public engagement lives up to the
rationales advanced for it is required.56
Clinical professionals and professional associations
Clinical professions must engage in robust, evidence-
based guideline development and implementation.
Clinical practice guidelines (CPGs) are systematically
developed statements to assist practitioner and patient
decisions about appropriate health care for specific clinical
circumstances.57 The majority of CPGs are developed by
medical professional organisations, govern­ment agencies,
and non-profit organisations. When guideline recom­
mendations are developed through a structured, evidence-
based process and applied by clinicians accurately, the
expected effect would be an increase in the use of
appropriate services and reduction in the use of
inappropriate or unnecessary services, thereby improving
outcomes, and potentially reducing net spending.
Several studies have assessed the impact of CPGs, and
systematic reviews of these studies have generally
concluded that CPGs improve both process and outcomes
of care, with substantial variability in the magnitude of
these improvements.58,59 Although some results are
encouraging, others are not,22 and the evidence also
strongly suggests that considerable variation exists around
the point estimates, which contain clues as to where to
focus remedial efforts. For example, audit and feedback
offers an average 4·3% improvement in adherence to the
guidelines, but an upper range of 16% when key
considerations are addressed.60 CPG implementation
strategies must be customised to the individual guideline
and clinical conditions, with attention to the barriers to
196 www.thelancet.com Vol 390 July 8, 2017
change identified in each context.25,61 Overall, the evidence
shows that none of the approaches for transferring clinical
guideline recommendations to practice is effective across
all possible situations.62 Additionally, patients with
multiple comorbidities can trigger recommendations
from multiple CPGs, without providing clear guidance on
how best to prioritise the interventions, potentially leading
to overtreatment.63
Perhaps the most important limitations to the potential
for CPGs to reduce both underuse and overuse are
the substantial gaps in evidence on which to base
recommendations, biased evidence, and biased guideline
producers. A review of 16 CPGs from the American
College of Cardiology64 showed that only 314 of
2711 recommendations (median 11%) are classified as level
of evidence A (ie, multiple randomised trials or meta-
analyses), whereas 1246 (median 48%) are level of evidence
C (ie, expert opinion, case studies, or standards of care).
Moreover, many guidelines offer advice of questionable
value to patients, as a result of industry influence.65,66 The
shortage of good quality evidence suggests that a crucial
strategy to reduce the prevalence of inappropriate care will
be at least two-fold, involving substantial expansion of
efforts to address these gaps in evidence through more
relevant and higher quality clinical research,67–69 and closer
adherence to best practices for reducing bias due to
conflicts of interest.70
Closely related to bias due to conflicts of interest, and
poor quality research, is the ever-expanding number of,
and definitions for, diseases that then require additional
research. An urgent need exists for unbiased, evidence-
based generation and consensus for creating and
modifying disease definitions. No global rules or referees
have been identified to oversee the development of new
disease and predisease definitions, including the so-called
threshold creep of disease classifications.71 Such a body is
required to modulate the rise of overdiagnosis and
resultant overtreatment, which might include revisions to
treatment recommendations based on risk profile of
treatment versus no treatment, and prognosis.
Trends are also shifting internationally with pro­
fessionals now being explicitly directed to consider the
cost of interventions, with a responsibility to reduce
waste and improve the value of care. This shift is
occurring via many of the financial incentive levers
presented throughout this Series paper, but also through
efforts such as the Lean method72 to improve process
efficiency; education at the graduate level;5,73 and explicit
guidance—eg, from The National Institute for Health
and Care Excellence28 and Choosing Wisely.18
System leaders
System leaders are defined as civil service administrators
and those in executive positions at arm’s-length
government organisations (eg, safety and quality
commissions), non-government organisations, and
third party payers or insurers. The role for system

leaders in achieving the right care is extensive. In this
section, we discuss potential leverage points in the
delivery, financial, and governance arrangements within
which care is provided.
Foremost at the delivery level is a robust primary care
system.74 International comparisons of health outcomes
in various health-care systems have shown the importance
of primary care for driving appropriate care. The provision
of ready access to robust high-quality primary care
underpins many of the leverage options discussed in this
Series paper, from bolstered SDM to integrated care.75,76
All levels of care could benefit from a comprehensive,
regionally integrated health information technology
(HIT) infrastructure, complete with electronic health
records (EHRs), and computerised physician order entry
(CPOE) systems. EHRs with CPOE designs can include
algorithms, clinical pathway analysis, utilisation and
cost information, vetting of orders, and restriction of
tests to ensure an appropriate test repertoire. Many HITs
and EHRs now have such decision tools, all of which
could be used to prompt appropriate high-value care.77
To date, individual studies have shown little effect of
EHRs for elements of quality improvement,78 but
knowledge is building of the conditions through which
single-component versus multifaceted inter­ventions are
more or less effective in changing clinical behaviour.79,80
A systematic review81 identified 19 studies of the impact
of CPOE on laboratory testing. The CPOE systems
(both with and without decision support) showed an
overall trend towards reduced test volume and cost,
when compared with no CPOE. Overall, fewer tests,
fewer inappropriate tests, and a considerable reduction
in the median time to appropriate treatment occurred in
the decision support group. These positive results must
also be viewed against concerns that first generation
EHRs focus excessively on revenue enhancement in
some health systems, are too rigid to allow appropriate
individualisation of care, and detract from other, equally
important aspects of the right care— eg, eye contact and
empathic listening. These issues require urgent research
to help inform the incorporation of human design
factors and the evolution of more intelligent algorithms.
The structuring of financial incentives and payment
rules to support the right care is undergoing renewed
attention internationally, with explicit endorsements to
link payment with some aspects of quality. For example,
a 2013 US Institute of Medicine review of cancer care in
the USA82 called for Medicare and other insurers to
recognise and compensate providers that follow the
Choosing Wisely recommendations. Many countries
are implementing financial incentives for patients (eg,
co-payments and conditional cash transfers), as well as
rewards or penalties for clinicians, clinics, and hospitals.
A set of financial leverage options are listed (the table).
Furthermore, system leaders are exploring initiatives
intended to promote rapid adoption of high-value
innovations, particularly those that have the potential to
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Series
displace existing lower-value interventions. The MaRS For the MaRS EXCITE
EXCITE programme is one example whereby the needs programme see http://www.
marsdd.com/systems-change/
of patients, as well as the evidence requirements of mars-excite/mars-excite/
regulators and funders, are prioritised at the
development phase, rather than later when a product or
service has diffused through a system only to be deemed
inadequate on the grounds of safety, effectiveness, or
cost-effectiveness and when considerable risks to
patients and wasted resources could have already been
incurred.83,84 This programme sets a vision for nations to
fund large patient-relevant clinical trials to balance those
dominated by product development cycles of industry;85,86
to establish regulatory standards attentive to superiority
when patent protections are sought, and where
equivalence or non-inferiority triggers downward pricing
pressures; and to fund research to investigate services
without prospect for short-term profit.
To avoid both overuse and underuse, system leaders
must also appraise their systems’ investment in such
resources as per capita clinical labour and hospital beds.
It is widely understood that underuse can occur when
availability of resources is inadequate. If a country does
not have enough doctors and nurses, citizens’ health-care
needs will not be adequately addressed. The effect that
excess capacity can have on overuse is less well
recognised, particularly of services that are delivered at
the physician’s discretion, such as follow-up visits and
treatment in hospital.87
Geographical variation in supply-sensitive services
poses a problem for all system leaders who would aim to
match the capacity of their delivery system to the needs of
the population. Many of the methods used to detect a
need for increasing per capita supply of resources, such
as hospital occupancy rates, and primary care physicians
who are able to accept new patients, do not always provide
an accurate indication of need for additional beds and
personnel. Some efforts to curb excess hospital capacity,
such as certificate of need legislation, have had highly
variable effects by region, depending upon the political
power of existing hospitals to either gain permission to
expand or to exclude competitors. Perhaps the best way
for system leaders to determine the right capacity to meet
local health needs is by looking to systems that have good
outcomes using the least resources.27,88
Government policy makers
Mobilising system leaders (eg, bureaucrats) often requires
high-level political will and permission, support, or
mandate from politicians specifically. This mobilisation is
crucial for the scoping of any structural reforms through
to their implementation, particularly when broad-based
stakeholder commitment, large-scale infrastructure
investments, or legislative change is required.89
We advocate for systematic priority-setting processes as
a core requirement for countries to purchase high-value,
appropriate care. HTA, for example, is now firmly
engrained worldwide in the health-care resource
 Series
Panel 3: Caesarean (c)-section approaches that show
promise with regard to reducing overuse of care32
• In 2012, Italy set regional targets for c-section incidence,
which probably helped reverse the trend in c-section
incidence in provinces with the highest rates.
• In Spain, some hospitals used a clinical support tool to
assess the need for c-sections, which led to a small
reduction in use.
• Hospitals in Belgium received feedback on variations in
c-section incidence, which led to a convergence in rates
among hospitals with both high and low incidence.
• Several countries have introduced financial incentives.
France reduced the gap between the prices paid by health
insurance for c-sections and normal delivery. Similarly,
England decided to align the prices of the two procedures.
Korea implemented a pay-for-performance scheme for
hospitals, which slightly reduced c-section rates.
C-sections represent a tale of two extremes: a considerable
underuse problem in the lower-income and
lower-middle-income countries coexisting with overuse.
On the one hand, skilled resources and infrastructure might
not be available in rural and remote areas in which they are
needed to prevent maternal mortality; on the other hand,
urban and higher-income contexts face similar overuse issues
as high-income countries.
allocation infrastructure (with the notable exception
being the USA), but HTA is not a lever per se, but rather
a priority-setting feeder for leveraging safe, effective,
and cost-effective health care. In many countries, the
government must endorse this approach, support its
capacity, and follow through on its evidence-based
findings.90
Although HTA and associated economic evaluation
processes have become indispensable, especially
regarding the value-based purchasing of pharmaceuticals,
these processes have predominantly focused their
attention on new and emerging health services and
technologies. Little capacity exists for assessing services
and technologies that are already established within
health systems, but that nevertheless offer no or
low-value. This situation has been referred to as being
“stuck with the old and overwhelmed by the new”.20 Many
countries are realising this shortfall, and expanding the
focus of HTA to include reviews of well established
services (health technology reassessment [HTRA]).39
Both Canada (Ontario) and Australia, for example, have
developed successful HTRA initiatives within their
fee-for-service systems.91,92 For other countries, the
introduction of robust HTA and HTRA processes
represent a key step towards encouraging the prevention
of underuse and overuse.93 In recognising this potential,
particularly for low-income and middle-income countries
(LMICs), the Bill & Melinda Gates Foundation has
198 www.thelancet.com Vol 390 July 8, 2017
provided a grant to the International Decision Support
Initiative, supporting governments of LMICs and donors
in making resource allocation decisions for health care,
guiding options for the design, adjustment, and
assessment of health benefit plans in the context of
UHC.94 Some leverage points (table) have considerable
potential for implementation to support UHC, as a result
of robust HTA and HTRA processes.
An extension of HTA processes would see health
systems incorporate public reporting, such as the
increasing trend in several countries to publish atlases of
variation for the first time.32 Some Organisation for
Economic Cooperation and Development countries are
becoming quite sophisticated in how information is
presented, as seen in England through the National
Health Service Atlas, Outcomes benchmarking support
packs, and the Commissioning for value data pack.95 Italy
has been particularly successful with target diagrams so
policy makers can make sense of them.32 Systematic
reporting for a select number of high-cost, high-volume
procedures allows scope to identify outliers, and creates
opportunity for discussion with local decision makers
and providers (panel 3). Local-level analysis is superior to
patient-level data to identify possible unmet needs.
Patient data help to contextualise patients who received
low-value care31 with potential also to identify patients
who required treatment but did not receive it.59 Another
soft touch policy that shows promise is setting regional
or local targets; Italy (eg, for select health-care activities)
and Belgium (eg, diagnostic imaging) have had success
in this area.32 Although multiple policies and approaches
are necessary, the relationship between policy type and
the effect on regional variations shows mixed success.
Pay-for-performance has been widely used for
addressing underuse of high-value services in a wide
range of health systems in both high-income countries
and LMICs. Although financial incentives are clearly
important as drivers of health-care use, the success
of pay-for-performance approaches has been mixed,
perhaps because of limitations in both the design and
implementation of incentives,96,97 but just as likely
because these approaches are inadequate single-focus
solutions to complex problems. Moreover, as a lever
for addressing overuse, pay-for-performance is largely
untested, but would need to overcome existing financial
incentives (eg, fee-for-service), as well as other drivers of
overuse. In a somewhat different frame, payers have
introduced schemes that withhold payment for services
that resulted from a preventable complication or penalise
hospitals for high rates of avoidable re-admissions and
complications.98,99 Controversy has arisen, however, about
appropriate accounting for patient risk factors and it is
unclear how effective such negative payment incentives
will be relative to alternatives.100
Alongside HTA and HTRA infrastructure support and
targeted financial incentives, funding and payment
structures govern the general flow of resources through

the health system. A spectrum of approaches exists to
fund the delivery of health care from global budgets
attached to a specific structure (such as a hospital),
whereby payment is completely detached from the
delivery of services, to fee-for-service or cost-based
reimbursement, in which payment is strictly linked to the
number and intensity of services. Many health systems
rely on fee-for-service to pay for physician and ancillary
services and research has shown that related pricing
distortions (specifically, differential profit margins across
services) can drive both underuse and overuse. Moreover,
even in health systems that rely more heavily on block
funding, isolated payment arrangements that prevent the
funds from following patients across sites of care can lead
to both underuse and overuse. As a result, many countries
are looking to create organised networks of providers
with financial accountability for quality (including
outcomes), patient experience, and the total cost of care.
The US Affordable Care Act introduced the option for
Medicare to pay so-called accountable care organisations
on the basis of a virtual global budget for all patients who
use the primary care services of the system.49,50 Some
accountable care organisations share both upside and
downside risk relative to a spending target for the
population, and payments are also affected by per­
formance on a set of quality measures. In England,
clinical commissioning groups and other new entities
foreshadowed by the 2014 National Health Service 5-year
Forward View95 adopt a similar role as the nexus of health-
care prioritisation at the local level. Similar accountability
models can also be designed around a narrower set of
services, such as those indicated for the treatment of a
condition or related to an acute episode, such as a hip
fracture. The Netherlands have introduced episode-based
payment for diabetes care, prepaying for a defined set of
recommended services to encourage local care groups of
general practitioners to reduce costs.101 Furthermore,
more than 300 million new insurance beneficiaries in
publicly funded health insurance programmes in India
are now covered for hospital costs through single, pre-
agreed grouped payments, which even include
transportation and medicines provided at discharge.102
In theory, global payment—at either the population
(also known as capitation) or episode level—encourages
the accountable provider to consider both the costs and
benefits of every service and thus increase the value of
care delivered. Indeed, burgeoning research shows that
global payment can reduce cost relative to fee-for-service
contracts and disproportionately diminishes low-value
services.49,103 However, whether global payments could
also reduce the use of high-value services is unclear.
In European countries, efforts to introduce bundled
payment for services closely linked to clinical guidance
are showing promise,104 leading to better protocols and
standards of care (Netherlands, Portugal, Sweden).
However, episode-based payments could have some
downsides relative to population-based global payment
www.thelancet.com Vol 390 July 8, 2017 199
Series
because providers can induce unnecessary episodes of
care or push care outside of the funded group, resulting
in the appearance of savings at one level, but not from
the broader payer’s perspective.105–07 Incremental changes
to systems that rely heavily on fee-for-service are a
necessary part of addressing overuse and underuse.108
Evidence suggests that the level of fees both in absolute
and relative terms affects the frequency of use of
individual services, suggesting that adjustments to fee-
for-service that shift the emphasis from low-value to
high-value care is a policy worth pursuing.109
Furthermore, reducing the fear of litigation through
so-called no fault systems provides important
opportunities to enable clinical decision making to be
about the patient and nothing else.110
Implementation considerations and fit-for-purpose change
As we have noted in paper 3 of this Series,3 key drivers of
care operate at the global level. These drivers include
trade agreements, international aid, media networks,
multinational corporations, and, increasingly, pro­
fessional societies. Traditional intergovernmental global
health organisations have to date played a small role in
efforts to improve quality of care delivery. Much work is to
be done by international institutions to develop adequate
frameworks for promoting the right care around the
world, such as establishing international guidelines to
ensure high-quality standards for biomedical research,
open access to clinical data, and widely accepted codes of
conduct for health-care professionals.
The international initiatives discussed within this
Series paper are instructive. An analysis of these
initiatives highlights numerous shared challenges.
Comprehensive and lasting reform requires the following
approaches: collective acknowledgment of the concurrent
problems of overuse and underuse; the generation of
will—political, professional, and social—for broader
stakeholder support and the process of carrying reform,
with ongoing stakeholder consultation and participation;
high-level commitment to ensure that priority setting is
part of an explicit, formal, and well resourced policy
agenda beyond short-term political timelines; transparent
decision making frameworks removed from vested
interests; clear objectives and nomenclature, articulating
an ethic of waste reduction, and minimising opportunity
costs rather than rationing; and the allocation of resources
for data collection, monitoring, analysis, and sharing. We
must acknowledge that research evidence in this domain
is a necessary, but not sufficient ingredient for change.
Research waste, bias, and residual uncertainty is simply
too prevalent to assume that the evidence alone will steer
the course towards the right care.69 One key tenet should
be that the burden of evidence for safety, effectiveness,
and cost-effectiveness rests with the product developer or
sponsor, not patients and payers (including tax payers) of
health care. An important perspective would hold that
entrenched legacy services ought to also be subjected to
 Series
the rigorous standards that are increasingly applied to
new and emerging technologies and practices. If, after
years of use, evidence is not balanced in favour of a
practice (and some doubt exists) then a precautionary
perspective appears warranted. Restoring the burden of
proof is one possibility—placing the inferred expectation
for scientifically robust demonstrations of safety,
effectiveness, and cost-effectiveness back on the sponsor
of a product. Overcoming political, professional, and
social resistance to change is a key implementation
consideration. However, a shift is undoubtedly occurring
in this regard internationally, posing a wonderful
opportunity for effective change.
Conclusions
The modern history of health care is littered with policy and
practice inaction in the face of inappropriate care, often
justified by an absence of evidence or uncertainty about
what might result—Machiavelli’s “new order of things”.111
This lack of action should no longer be acceptable.
Although the scale of the problem is vast and complex, a
range of potentially effective remedies are available, with
many more needed. Evidence-based medicine, HTA,
shared decision making, and countless other movements
have surely nudged health systems to a point whereby we
must ultimately acknowledge that a decision not to act is
still a decision, and one with implications for people’s
health. As efforts to improve the delivery of care continue
worldwide, we must recognise that if the objective is to
improve health, delivery systems need to be properly scaled
and adapted to local needs and socioeconomic conditions
to be maximally effective. Furthermore, delivery system
leaders should remain humble about their systems’
contributions to health and should be unburdened from
the task of substituting less effective medical spending for
social spending. Transitions from the norm invariably
cause conflict, but if efforts to achieve the right care are able
to capture the full opportunity in front of us, the benefits to
the wellbeing of patients, professionals, and the public as a
whole are too great to condone inaction.
Contributors
AGE, SB, MBR, PL, JNL, HS, ST, and VS drafted the outline. AGE led
the redrafting; first draft construction of panels were led by AGE, JNL,
MBR, VS, and SB (panel 2), VS, SB, and AE (panel 1), AE (table first
draft), AE, SN, HS, and PL (table second draft), and DS (panel 3), with
subsequent input from all authors on all panels. All authors led a section
of the manuscript and cross-contributed to sections and examples
throughout the paper, provided substantial revisions, and approved the
final version of the manuscript.
Declaration of interests
AGE receives salary support as the HCF Research Foundation
Professorial Research Fellow, and holds research grants from The
Commonwealth Fund and Australia’s National Health and Medical
Research Council (ID 1109626 and 1104136); receives fees for consultancy
and advisory board membership from Cancer Australia, the Capital
Markets Cooperative Research Centre-Health Quality Programme, NPS
MedicineWise (facilitator of Choosing Wisely Australia), The Royal
Australasian College of Physicians (facilitator of the EVOLVE
programme), and the Australian Commission on Safety and Quality in
Health Care; and is a member of the Australian Government Department
200 www.thelancet.com Vol 390 July 8, 2017
of Health’s Medicare Benefits Schedule Review Taskforce. MBR has been
supported by grants from the Robert Wood Johnson Foundation Health
Care Financing and Organization Program, the Commonwealth Fund,
and the Peter G Peterson Foundation for research related to the Choosing
Wisely recommendations in the USA; and serves as board chair for the
Massachusetts Health Quality Partners. JNL receives salary support as
the Canada Research Chair in Evidence-Informed Health Systems; and
directs the McMaster Health Forum, which receives financial support
from a broad range of governments and stakeholder groups (but none
with a commercial interest in particular technologies). PL was the
founding clinical and public health director of the National Institute for
Health and Care Excellence from 1999 to 2012 and is now supported by
the National Institute for Health Research Collaboration for Leadership
in Applied Health Research and Care South London at King’s College
Hospital National Health Service Foundation Trust. VS and SB are
supported by the Lown Institute and receive grants from the Robert
Wood Johnson Foundation. Views expressed by the authors are their own
and do not necessarily represent the views of their employing, affiliated,
or associated organisations, or the official views of the Organisation for
Economic Cooperation and Development member countries. HS, SN,
DS, and ST declare no competing interests.
Acknowledgments
Work for this Series paper was funded by The Commonwealth Fund, a
national, private foundation based in New York City that supports
independent research on health-care issues and provides grants to
improve health-care practice and policy. The views presented here are
those of the authors and not necessarily those of The Commonwealth
Fund, its directors, officers, or staff.
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Profile
Vikas Saini: leading activist in the Right Care Alliance
Without a clinic or a laboratory, Vikas Saini could feel out
of his comfort zone, but as President of the Lown Institute,
located in Brookline on the outskirts of Boston, USA, he does
not have much time to reflect on his previous life. Having
trained as a cardiologist under the great Bernard Lown, Saini
now heads up the non-profit organisation founded by his
mentor in the 1970s. “Bernard thought his vision for patient
care should become part of a national conversation within
the US. The work I do now is a natural extension of this,
which has led to a focus on medical overuse and underuse
within the US health system”, he says. One outcome of
Saini’s work in this field is the publication of the Lancet Right
Care Series, which Saini has led. Shannon Brownlee, a Series
co-author and colleague at the Lown Institute, comments
that “I’m still amazed by his ability to integrate disparate
fields of scholarship ranging from critical appraisal of clinical
research to the history of social movements. I think this
ability to surf multiple waves of thought makes him willing
to take on audacious projects, including our Lancet series.”
Part of Saini’s role at the Lown Institute is to grow a
grassroots movement, the Right Care Alliance, to become
a leading voice for change in the way US health care is
delivered. “The aim of the Alliance is to create public
demand for a health system that is universal, safe, and
effective, and that delivers the right care. One current
project is to motivate people to sign up and help define a
top ten priorities list: not only the five things we shouldn’t
do that we currently do, but also the things we should be
doing. The aim is to have local and national impact by
encouraging people to link up and exert pressure on what
an affordable, fair health system should be”, he says.
Born in the Punjab region of northern India, Saini’s scientist
parents moved to the USA when he was 4 years old, later
settling in Fredericton, New Brunswick, Canada. Saini took a
philosophy undergraduate degree at Princeton at the height
of US involvement in the Vietnam War. “My main passions
were in studying literature, history, politics—and, the most
important aspect of being a student, in thinking deeply
about the world around us”, Saini recalls. It was while taking
a year out from his studies, travelling overland from Europe
to India, that the idea of medicine gradually took hold. “It
was during that long journey that I first saw the deep ocean
of need in the world, and realised how politics could not help
with the same certainty that medicine could”, Saini says.
By 1980, Saini had qualified from Dalhousie Medical School
in Halifax, Canada, including a year out working at New York
City’s Montefiore hospital on a survey of toxic exposures
of chemical workers. He drove a cab to make ends meet;
his fares included Dan Aykroyd and Andy Warhol. “That
experience grew my understanding of American society, and
www.thelancet.com Vol 390 July 8, 2017 117
Perspectives
I found myself arguing with passengers, especially those I
picked up around Wall Street”, Saini recalls. During residency
at Hopkins Bayview Hospital, he became fascinated by
cardiology, and the coronary care unit. He became especially
interested in the psychosocial aspects of cardiovascular
disease, gaining a cardiology fellowship at Johns Hopkins,
and an epidemiology scholarship at the Johns Hopkins
Bloomberg School of Public Health. “It was at this time that
I first came into contact with Bernard”, Saini says. “I became
fascinated by his work on psychological stress on the heart.
I told him I was fully funded, and would love to spend some
time to come and work in his lab at Harvard. He said no.”
Published Online
The only condition that Lown would accept was for January 8, 2017
Saini to leave Johns Hopkins and become a Research http://dx.doi.org/10.1016/
S0140-6736(16)32622-8
Fellow under Lown at Harvard. Saini moved to Boston,
See Series pages 156, 169, 178,
relishing work in the laboratory, studying the effect of
and 191
neurotransmitters and endogenous opioids on cardiac
For the Lown Institute see
function. His clinical work opened his eyes, too: “It was http://lowninstitute.org/
during the mid-1980s when I truly discovered myself as For the Right Care Alliance see
a doctor. On the wards we took a very holistic approach http://rightcarealliance.org/
with patients, trying to understand the psychology that
often related to their health situation. Our focus then was
humanistic. We had deep contact with our patients, a
revelation to me about what doctoring could be like.”
A close collaboration with Nassib Chamoun, a graduate
student engineer in Lown’s research laboratory, led to a new
phase in Saini’s career, as he and Chamoun set up Aspect
Medical Systems in 1987. Originally intending to develop non-
invasive monitors for sudden cardiac death, the company
expanded by developing state-of-the-art technology for the
first widely used monitor to measure consciousness during
anaesthesia. “I felt odd, as a trained cardiologist, not seeing
patients, developing a business in anaesthesiology”, he says.
He left to reconnect with clinical work, establishing a busy
cardiology practice in New England.
Harvard became Saini’s professional home once again
in 2007, where he returned to lead the Lown Institute and
co-directed Bernard Lown’s practice group. Increasingly
concerned with the problems in the US health system, Saini
collaborated with Brownlee, author of the book Overtreated,
to organise a meeting in 2012 entitled Avoiding Avoidable
Care. “The 2012 gathering was the first academic meeting
to discuss the problem of overtreatment and triggered a
remarkable outpouring of interest and support; it catalysed
our current and future thinking and led to the creation of
the Right Care Alliance. There’s no going back. Right care
advocates are going to have increasing influence on the way
US health services are organised”, Saini says.
Richard Lane