Trends in the Overuse of Ambulatory Health Care Services in the U.s

Context—Given the rising costs of health care, policy makers are increasingly interested in identifying the inefficiencies in our health care system. Objective—To determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade. Design and Setting—Cross-sectional analysis of the 1999 and 2009 National Ambulatory Medical Care Survey (NAMCS) and the outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS), which are nationally representative annual surveys of visits to non-federally funded ambulatory care practices. We applied a total of twenty-two quality indicators using a combination of current quality measures and guideline recommendations. Main Outcome Measures—We estimated the rates of underuse, overuse, and misuse and their 95% confidence intervals. Results—We observed a statistically significant improvement in 6 out of 9 underuse quality indicators. There was an improvement in the use of antithrombotic therapy for atrial fibrillation, the use of aspirin, beta blockers, and statins in coronary artery disease, the use of beta blockers in congestive heart failure, and the use of statins in diabetes. We observed an improvement in only 2 of 11 overuse quality indicators, 1 indicator became worse and 8 did not change. There was a statistically significant decrease in the overuse of cervical cancer screening in visits for females Corresponding author: Minal S. Kale, M.D.; Division of General Internal Medicine; Mount Sinai School of Medicine; One Gustave Levy Place; Box 1087; New York, NY 10029; Tel.: (212) 824-7492; Fax: (212) 824-2317; [email protected]. Author Contributions: Study concept and design: Kale, Keyhani. Acquisition of data: Kale. Analysis and interpretation of data: Kale, Bishop, Federman, Keyhani. Drafting of the manuscript: Kale, Keyhani. Critical revision of the manuscript for important intellectual content: Kale, Bishop, Federman, Keyhani. Statistical analysis: Kale Administrative, technical, or material support: Kale. Study supervision: Keyhani. NIH Public Access Author Manuscript JAMA Intern Med. Author manuscript; available in PMC 2013 September 18. Published in final edited form as: JAMA Intern Med. 2013 January 28; 173(2): 142–148. doi:10.1001/2013.jamainternmed.1022. N IH PA Athor M anscript N IH PA Athor M anscript N IH PA Athor M anscript older than 65 and in the overuse of antibiotics in asthma exacerbations. However, there was an increase in the overuse of prostate cancer screening in men older than 74. Out of the 2 misuse indicators, there was a decrease in the proportion of patients with a urinary tract infection who were prescribed an inappropriate antibiotic. Conclusions—In our examination of ambulatory care in the U.S., we found significant improvement in the delivery of underused care but more limited changes in the reduction of inappropriate care. In an era of heightened alarm about the high cost of healthcare, these results are especially concerning.