Do we over utilize or under utilize health care resources?

In popular debate surrounding health care these days the politically correct answer is that we over utilize, but is that really true? A careful look at all the evidence ought to lead to a more nuanced discussion.

Kevin MD talked about over utilization in a recent post: Unnecessary tests and treatments are commonly ordered for patients. He made some interesting points but I must respectfully disagree with his conclusion about an MSNBC (Associated Press) piece he cited:

Just when I’ve lost hope that mainstream media will stop perpetuating the myth the more medicine equals better care, the Associated Press came up this excellent piece.

...Responsible reporting like this can help sway some patients to be more critical of their physician’s recommendations.

...But to reach patients, mainstream media needs to pick up the baton and run with it. More articles like the AP piece would be a great start.

Articles like this are exactly what we don't need shaping public opinion and driving policy. Like much reporting in the popular media it's little more than a smattering of factoids and opinions form here and there, cherry picked to suit the author's biases, with no citation of primary research literature.

So what's the real truth in the too much versus too little debate? The answer is not headline grabbing stuff. We do a lot of both, and we lack a clear answer on which side we err overall. There is much research evidence, in fact, suggesting we do too little as demonstrated in this landmark paper. While that paper doesn't tell the whole story it's some of the best evidence we have to address the issue. And there's more. Look at device therapy for heart failure. Vastly under utilized, and expensive. What about statin drugs? Widely under prescribed when looked at against evidence and guideline recommendations. And while we know lots of kiddos get antibiotics they don't need of ear aches this paper (and others like it) show that critically ill patients arriving at the ER all too often get single agent antibiotic therapy started when big gun combination therapy might be live saving.

So we don't really know. Sometimes less is better while sometimes more is better. We don't have an evidential bottom line. If we all practiced flawless evidence based medicine would costs go up or down? Again we don't know. Maybe we need an updated systematic review. This is not a systematic review.