Elsevier

The Lancet

Volume 390, Issue 10090, 8–14 July 2017, Pages 178-190
The Lancet

Series
Drivers of poor medical care

https://doi.org/10.1016/S0140-6736(16)30947-3Get rights and content

Summary

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and 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 poor care in each domain.

Introduction

Papers 1 and 2 in this Series outline the scope of poor care from both overuse and underuse of medical services.

Drivers of poor care reside in three major domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. Drivers operate in specific contexts and contribute to the overall quality and quantity of care delivered. These contexts are best considered as different levels in an ecosystem of care delivery: global; national, legal, regulatory, and cultural; regional, institutional, and social; and the individual locus of the doctor–patient relationship.

Multiple drivers of poor care interact throughout this ecosystem. We aim to outline a navigational chart for addressing this fundamental problem of modern health care. Reducing poor care will require a well contextualised, multidimensional, and concerted effort by health-care professionals, policy makers, and the public. Previous definitions of quality of care have focused on evidence-based health outcomes of individuals and populations incorporating patient preferences.1 Our conception of the right care extends this definition further by including the importance of stewardship in the distribution of societal resources through what inherently is a political process.

Drivers at the global level affect multiple actors across all societies—for example, the mass media and multinational corporations. At national, regional, and local levels, variation in legal and regulatory regimes, power relationships among stakeholders, and cultural norms and traditions, act differentially. Social networks—of patients and families on one side and professionals and delivery systems on the other—act as local mechanisms of transmission of all drivers. Provider stakeholders, such as professional societies, operate locally, nationally, and increasingly, globally, to convey standards of practice, even as they legitimate clinicians' professional autonomy.

The creation and dissemination of knowledge occurs at various levels via multiple actors. However, care itself is initiated at the individual level from the centre of the ecosystem, where up to 80% of health-care costs are initiated.2 Here, the patient and the doctor sit, with their own individual and social identity, cultural and cognitive biases, and the cumulative influence of the forces surrounding them. These individuals also bring their experience, emotion, transference, and countertransference to the encounter.3

Numerous additional variables exist within this relationship, including the clinical calculation of benefits and harms, patient preferences, physician preferences, provider training and competence, available infrastructure, financial incentives, trust and understanding between patient and clinician, and the influences of others, both individually and through social networks. Clinical decision making emerges from this complex interaction. In this Series paper, we describe the major drivers of care and how they operate.

Key messages

  • The biomedical model of the past century has been valuable for some aspects of medicine and is a necessary, but not a sufficient, component for the proper care of patients

  • The biological, psychological, and social needs of patients and informed preferences must define desirable outcomes and appropriateness of care

  • Greed, competing interests, and poor information are universal drivers of poor care that occur across all systems and settings

  • Inaccurate knowledge and information of all stakeholders regarding effective and ineffective care is a key driver of poor care

  • The levers for knowledge dissemination and adoption of health technologies are too often distorted by a fascination with innovation, which is reinforced by vested interests

  • Systemic factors, cognitive frameworks, and cultural influences, particularly regarding health, health care, science, and technology, are important drivers of care and have to be understood to improve health-care decisions at all levels

  • The way in which each health system is organised and financed, and how resources are allocated towards facilities and workforce, allows each of these drivers to have more or less influence

  • The substantial economic interests of the health-care industry and the alignment of incentive structures within health services are major drivers of potentially biased knowledge generation and health-care delivery worldwide

  • Failure to reinforce professional ethics and protect the therapeutic relationship from financial concerns distorts medical care

  • Regulatory capture, disempowerment of communities and citizens, and a political aversion to priority setting all drive poor care

Understanding these drivers and the various ways in which they act across systems provides opportunity to increase the social and individual value of care

Section snippets

Health coverage, resource allocation, and the organisation of care delivery

Overuse and underuse of care exist in all types of health-care systems.4, 5, 6 However, financing arrangements influence the relative strength of the various drivers and how they contribute to poor care (figure 1).

Inadequate health coverage is a primary cause of poor care. For example, people who are uninsured or underinsured often forego or are denied essential care because of an inability to pay.6, 7 Decisions about what is covered and accountability for appropriate clinical decisions

Influence on clinicians' behaviour

Systems of payment influence the behaviour of health-care professionals.26, 27 Fee-for-service or volume-based payments encourage the provision of covered services in contrast to capitation or salaries for health professionals that do not. Standards of professionalism alone cannot ensure that services delivered serve patients' interests.26

Physicians routinely act in conformity with their financial interests. Under fee-for-service payment, many specialties deliver higher volumes of services,

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

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, 155, 156 In the absence of mutual respect and trust, an inadequate

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

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