Forum Focus – When less is really more … using medical resources appropriately

By John R. Combes, MD, senior vice president, American Hospital Association, and Elisa Arespacochaga, director, Physician Leadership Forum

appropriate_use_coverMedical knowledge has increased exponentially over the past 20 years, and clinical knowl­edge is doubling as fast as every two years. However application of some of this knowledge has not led to improvement in outcomes or health. While cutting edge surgeries, cures for once devastat­ing diseases, and tools to manage chronic illness have all been great boons to society, other treatment and procedures have added little or no value to the care of patients and have increased costs. With all this knowledge looms a larger debate, when are we doing too much and how do we decide?

Several decades ago, utiliza­tion review was as essential to health care discussions as qual­ity and patient safety are today. But as safety and quality became an organizational priority, there has been less vigorous review of appropriateness. As health care becomes more complex and technology driven, it is important that we not fall under the spell of treating those things that are identified, but have little clinical consequence, and might benefit from watchful waiting or less aggressive interventions. Care providers endeavor to provide the most appropriate care to patients regardless of cost, but all too often there isn’t enough discus­sion with patients about what is appropriate. Will this test or pro­cedure improve the patient’s out­come and is it consistent with the patient’s values and goals? Further, how can the health care system equip patients to participate in those dis­cussions and make the most informed deci­sion in partnership with their caregivers?

Continuing public concern about the cost of health care and the opportunities to prevent unnecessary harm to patients has prompted clinicians and policy­makers alike to take a hard look at the appropriate use of care resources. As medical societies, provider organizations, and oth­ers look for ways to drive appro­priate use of medical resources, hospitals and health systems can play an important role in sup­porting and guiding these efforts.

A path forward. We can take steps to manage health care costs while also improving health outcomes. How? The answer is straight­forward: Use medical resources appropriately. By reducing the utilization of non-beneficial care – care that increases costs without a concomitant increase in value – we can have a delivery system that achieves the triple aim of improved health, a quality patient experience and lowered costs.

Over the past year, the AHA with guidance from its Committee on Clinical Leadership, Physician Leadership Forum, regional policy boards, and governing councils and committees, exam­ined and discussed the appropriate use of medical resources. The outgrowth of those discussions is “Appropriate Use of Medical Resources,” a white paper shared with AHA members this week. It identifies the drivers of health care utilization and its contributing factors. More importantly, the paper recommends a way to move forward that will place hospi­tals at the forefront of innovative change for reducing non-beneficial services while improv­ing health care overall.

Hospital and health system approaches. As one of the more intense health care resource users, hospitals and health systems have a responsibility to encour­age appropriate and consistent use of health care resources and give providers the tools to better communicate with patients about appropriate use.

As your national association, the AHA is pursuing change through several avenues. Among our efforts, we have developed a “top five” list of hospital-based procedures or interventions that should be reviewed and discussed by a patient and physician prior to proceeding. These are:

  • Appropriate blood management in inpatient services;
  • Appropriate antimicrobial stew­ardship;
  • Reducing inpatient admissions for ambulatory-sensitive condi­tions (like, for example, low back pain, asthma, uncompli­cated pneumonia);
  • Appropriate use of elective percutaneous coronary interven­tion; and
  • Appropriate use of the intensive care unit for imminently termi­nal illness (including encour­aging early intervention and discussion about priorities for medical care in the context of progressive disease).

To begin the discussion in your hospital and community, share “Appropriate Use of Medi­cal Resources” with your board, medical staff and community leaders and use the accompany­ing discussion guide to explore the issue together. It’s available at

In the coming months, the AHA will roll out resources tar­geting each of the five procedures or interventions listed above. We also will share best prac­tices from hospitals and health systems that are already on this path. If your organization is well on the path to adopting one, please share your story with us at Finally, the AHA will continue to work to reduce the barriers that inhibit hospitals’ efforts to provide the appropriate care at the appropri­ate time in the appropriate set­ting.