An Exploration of the Drivers of Medical Overuse Among Family Physicians: A Scoping Review

  

    
Themes
    
 
    
Subthemes
  
  

    
Physician-related drivers in    medical overuse
    
Physician's behavior 
    
Time constraints 
  
  

    
Family physician shortages 
  
  

    
Patient satisfaction 
  
  

    
Patient reassurance 
  
  

    
Personal routines 
  
  

    
Tolerance to diagnostic uncertainty 
  
  

    
Tactical motivations for requesting tests 
  
  

    
Physician's fear of litigation and the choice of    defensive medicine 
  
  

    
Previous experiences of non-diagnosis 
  
  

    
Physician’s belief 
  
  

    
Financial incentives 
  
  

    
Insufficient updating of knowledge by specialists 
  
  

    
Physician's soft skills 
  
  

    
Neglect of the psychological root of the disease or    illness 
  
  

    
Evidence-based medicine 
  
  

    
Patient-related drivers in    medical overuse
    
Patient's behavior 
    
Previous experience 
  
  

    
Patient's expectations 
  
  

    
Patient's demands
  
  

    
Health-system-related    drivers in medical overuse
    
System�    structure 
    
Misuse of diagnostic or therapeutic resources 
  
  

    
Upstream commitment 
  
  

    
Organizational structures and models of    compensation 
  
  

    
Monitoring systems 
  
  

    
Rules and regulations in requesting and    distribution 
  
  

    
Guidelines 
  
  

    
Laboratory equipment 
  
  

    
Funding for health care 
  
  

    
Cultural environment 
  
  

    
Technology-related drivers    in medical overuse
    
Technology improvement 
    
Pharmaceutical businesses 
  
  

    
Technological processes 
  
  

    
Health information sources 
  
  

    
Decision support technologies 
  
  

    
IT-based intervention 
  

Table 2: The themes and codes that emerged from the review.

Physician-Related Drivers of Medical Overuse

Physician’s Behavior

Several factors could cause doctors to overuse services. These include time constraints [22-24], family physician shortage, patient satisfaction, patient reassurance [23], personal routines [25], intolerance to diagnostic uncertainty [25,26], tactical motivations for requesting tests [25], physicians' fear of litigation and the choice of defensive medicine [23,25,27], previous experiences of non-diagnosis [22-25,28], internship, and management of anonymous patients who tend to increase doctors' feelings of uncertainty and anxiety [25].

Family physicians sometimes overuse healthcare services for fear of incorrect diagnosis or misdiagnosis. Because a doctor's misdiagnosis leads to incorrect prescriptions, patients are required to undergo expensive tests, imaging, and other treatments that, in many cases, do not contribute to the correct diagnosis of the disease [25]. In addition, sometimes, under the conventional belief that the poorer sections of society have a higher need for antibiotics due to their unhealthy living conditions, family physicians overprescribe antibiotics [24]. Financial incentives for some family physicians could lead to prescribing medications to satisfy the patient [23-25]. At the office, the doctor thinks they should prescribe something that will reduce the patient's pain or prevent possible infection, leading to increased use of antibiotics [28].

Inappropriate drug prescription has been seen among physicians in most countries. Many patients are prescribed medication they do not need, and the appropriateness of the prescribed medication has not been proven. Despite the positive aspects of drugs, unprincipled and inappropriate prescription harms patients [24,28]. Inappropriate and unnecessary drug prescription causes adverse side effects and increases the cost of health services and pharmacotherapy. Additionally, inappropriate prescription of antibiotics leads to inappropriate use and overuse of antibiotics, which causes adverse side effects and the creation of resistant microbial strains [28]. The overuse of antibiotics is due to the poor competence of prescribers and is more prevalent in developing countries, with more than 50% of patients being referred to primary care each year for antibiotic treatment, of which less than 40% need the treatment [28]. Overuse of drugs varies in different countries; drug prescription indicators are not optimal in developing countries, and the principal indicators differ from one country to the next. Overuse of drugs leads to drug resistance, wastes resources, and increases mortality. It indicates an almost high average number of drugs per prescription and weak adherence to the Essential Medicines List (EML).

Some studies have emphasized the role of primary care physicians (family physicians) as essential inducers of the overuse of antimicrobial drugs and inappropriate prescriptions [28]. Lack of sufficient diagnostic skills [23,28], imprecision in prescribing antibiotics [27,28], failure to comply with WHO prescription standards [28], failure to improve diagnostic and therapeutic skills through continuing professional education [23,28], personal paradigms of physicians [23,25,28], sharing of wrong knowledge and beliefs about the use of antibiotics, and the gap between doctors' knowledge and the correct antibiotic treatment for common colds [28] are factors influencing medical overuse.

Other causes related to the physician in medical overuse include out-of-date knowledge in specialists, poor physician soft skills [23], repeating things that have always been done [25], neglect of the psychological roots of the disease [23], physician's personality [23,27], medical experience, medical procedures [23], evidence-based medicine and guidelines [22,23,25,27,28], economic incentives [23,27], the influence of the pharmaceutical industry [23,24], and doctor shopping [23].

According to family physicians, medical overuse could increase unnecessary diagnostic tests and revisits that are not beneficial to the patient, leading to increased health care costs. Family physicians are concerned that medical overuse would lead to the misallocation of limited resources, causing lack of treatment in other areas of health care. Almost all family physicians consider medical overuse a significant problem and believe that about 40% of medical services are medical overuse. Medical overuse is a serious issue for family physicians, but the main drivers of overuse lie beyond the physicians' control [23,26].

Patient-Related Factors in Medical Overuse

Patient’s Behavior

Based on their previous experiences with the health care system, some patients have reached a high level of awareness of their rights as a patient and have understood the customer-centric approach of doctors. Most people see a doctor, preferably a specialist, as soon as the symptoms of the disease, even those of a simple cold, present and expect the doctor to prescribe medication for all of their symptoms. Consumerism (patients consider health care as their right), specific behaviors and individual irresponsibility, perceived demands or expectations, expectations for receiving capsules, pressure by them and their families for receiving antibiotics, significant need for reassurance, uncertainty about what needs to be done, finding secondary care professionals better qualified to deal with medical problems in general, requesting a large amount of counseling, and the idea that a good doctor prescribes an ultrasound and an x-ray are some of the issues surrounding patients when they are dealing with family doctors [24,26,27].

One of the main drivers is patients' expectations [23]. Patients who request diagnostic testing or treatment based on personal beliefs, the advice of other patients, or the Internet are also known to drive healthcare overuse. Suggested solutions for the reduction of health care overuse focus on shared decision-making and step-by-step diagnostic interventions [27]. In primary care, patients often request diagnostic tests, referrals to specialists, and medications, most of which are antimicrobials and painkillers.

In addition to the patient's fear of uncertainty about what is happening to them, there is also pressure from family members, the effects of health counseling and news on the Internet, headlines of medical advances, and new techniques in digital and print media. Safety arguments are helpful in reducing these kinds of patient requests [23]. In primary care, patients were much more likely to ask their family physicians than hospital physicians for tests and medical procedures (78% vs. 40%). The more patients insist on receiving services, the more family physicians provide unnecessary services, including laboratory tests and surgeries. Family physicians are more lenient towards patients' requests because they will face aggressive reactions if they do not accept their requests.

Health System-Related Factors in Medical Overuse

System Structure

Medical overuse could be one of the reasons for poor quality and misuse of diagnostic or therapeutic resources. Overuse of diagnostic and therapeutic resources exists in all specialties, in all health systems, and at all levels of the health care system and is a threat to patient safety and the stability of health systems. The initial focus should be on the overuse of resources, which exposes patients to harm and is also a crucial factor in the high cost of health care. Although there is little association between medical overuse and overall costs, it is associated with a reduction in medical overuse and a shift to less aggressive methods. Some estimates suggest that 10 to 30 percent of total health care costs are wasted due to overuse [27].

In addition to the role of family physicians in reducing overuse, there should be an upstream commitment among family physicians to decrease and support physicians' prescriptions. According to family physicians, preventing medical overuse requires extensive policy-making [27]. Organizational structures and models of compensation, lack of analysis of results and outcomes of referrals from family physicians to specialists [23], direct access to secondary care for patients [23,27], patients' desire for specialized diagnoses [23,26], inadequate information management between departments and providers, the difference in secondary care provided by specialists in inpatient and outpatient wards, shortage of psychologists, the influence of media [23], over-supply of drugs, the short expiration date of drugs [24], drug prescription by pharmacists (prescribed by non-physicians) [23,24], lenience of rules and regulations in demand and distribution [23], low efficiency of monitoring systems, lack of adequate laboratory equipment [24,28], lack of funding for health care, lack of physicians, and inefficient bureaucracy in the health care system [23] were other topics discussed in studies related to the health system regarding the factors that increase overuse.

The problem is that medical overuse is common knowledge and even driven by guidelines, protocols, and incentive systems. One of the factors influencing overuse is the guidelines for family physicians, which they consider out-of-date [22,23,27,28]. Excessively lenient guidelines have worsened the issue of medical overuse. Therapeutic guidelines are also suggested among the reasons for the overuse of antibiotics [22]. Because it causes bacterial resistance, overuse of antibiotics creates additional problems that harm not only individuals but also third parties and society as a whole.

The complexity of the factors affecting medical overuse and the potential of decreasing it should be analyzed systematically. Harm from overuse is part of everyday clinical practice in prevention, diagnosis, treatment, and rehabilitation. One of the factors related to the health system is creating a more extensive framework of legal protection for people who reduce medical overuse in practice. Management indices and annual or biennial objectives could be set concerning medical overuse, especially in areas where patient safety is most at risk. Although physicians are directly responsible for medical overuse, consideration should also be given to the role that patients' associations, accreditation system websites, and health newsmakers' associations could play in successfully reducing overuse. Revision of medical responsibility may lead to a reduction in invasive testing. Providing clear and direct information to the patient about the clinical and safety reasons why they are recommended to avoid specific tests or certain treatments is beneficial in decreasing overuse.

A recent review article outlined the causes of medical overuse in five areas: culture, the health care system, industry and technology, healthcare professionals, and patients and community. The findings of this study confirm that Norwegian general practitioners, such as health care system specialists, and the general public, think that taking excessive medical measures is better [26]. If the disease is not detected early, doctors will be responsible for this lack of diagnosis. Fear of non-diagnosis is common among physicians, patients, and the general public [25,26]. This cultural environment naturalizes consumerist attitudes toward health care and the assumption that medical technologies could alleviate uncertainty. In such circumstances, the ethical costs of harm resulting from medical overuse, loss of integrity among people, and unavailability of health services for vulnerable people are ignored or considered irrelevant [26].

Technology-Related Factors in Medical Overuse

Technology Improvement

The effect of pharmaceutical businesses on physicians' prescriptions is well known. The visits of pharmaceutical business agents significantly affect the physician's preferences in drug prescription [23,24]. Medical and technological processes, including new equipment, and new laboratory tests, also affect medical overuse [23].

The use of health information sources such as internet access or medical and health journals and newspapers could have numerous impacts on the patient's expectations and thus lead to specific changes in healthcare strategies and sometimes cause tension between the patient and the doctor. Overuse of diagnostic imaging techniques for patients with asymptomatic low back pain leads to an increase in costs and exposes patients to unnecessary harms such as radiation exposure and cascading medical procedures and expenses. However, both patients and specialists tend to ignore the damage caused by the overuse of preventive, diagnostic, and therapeutic tests.

Medical education alone is insufficient for rescuing the prescription of laboratory tests, and also, the experience is different in different countries. In Sweden, for example, education alone was sufficient to reduce the inappropriate use of general practitioners in the laboratory. However, for unknown reasons, the training of general practitioners failed to significantly change clinical practice concerning this particular issue for the current population of Finnish physicians. The purpose of decision support technology is to make optimal use of diagnostic tests in clinical practice by providing direct assistance for diagnosis and treatment by providing helpful advice on how to proceed. Computer support for clinical decision-making can also improve health outcomes and costs by preventing unnecessary overuse of diagnostic tests. Laboratory prescription forms might induce over-prescription if they have a straightforward design, and physicians who use these forms may not always consider the consequences of their actions. Therefore, the government should always be very critical of which electronic form to use for different types of prescriptions and which to avoid. The government could use IT-based interventions to modify clinicians' clinical behavior, hypothetically leading to significant cost savings [23]. The drivers of medical overuse among family physicians are shown in Figure 2 (Figure 2).

    

    

    Figure 2: Drivers of medical overuse among family physicians.