Older Adults’ Perceptions of the Causes and Consequences
of Healthcare Overuse: A Qualitative Study
Ariel R. Green, MD, MPH
, Monica Tung, BA
, and Jodi B. Segal, MD, MPH
Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA;
Johns Hopkins University School of Medicine, Baltimore, MD, USA;
Division of General Internal Medicine, Department of Medicine, Johns Hopkins
University School of Medicine, Baltimore, MD, USA;
Center for Health Services and Outcomes Research, Johns Hopkins University Bloomberg School
of Public Health, Baltimore, MD, USA.
BACKGROUND: Overuse of healthcare is pervasive in the
United States, often exposing patients to harm with little
likelihood of benefit. Older Americans are particularly
vulnerable to overuse and impacted by it, yet it is un-
known whether older patients perceive overuse as a con-
OBJECTIVE: To explore the experiences and perspectives
of older adults with respect to healthcare overuse in order
to develop a framework for understanding and reducing
overuse in older adults.
DESIGN: Qualitative study using focus group methodology.
PARTICIPANTS: Five focus groups were held with people
≥65 years of age (N = 38) in four senior centers in Balti-
more, Maryland, in 2016.
APPROACH: Transcripts were analyzed using qualitative
content analysis to identify major themes.
KEY RESULTS: Of the 38 participants, 28 were wom-
en and 29 were African-American; 31 had at least a
12th grade education. While virtually all reported
experience with what they perceived to have been
healthcare overuse, some expressed concern that
they had been denied appropriate care. They per-
ceived overuse to have occurred when interventions
were applied in the absence of symptoms (excluding
cancer screening), did not improve symptoms, were
discordant with their preferences, or were duplica-
tive. Some defined overuse as interventions that were
offered before less intensive options or too early in
the course of disease. Suggested contributors to
overuse were poor quality communication between
patients and healthcare providers, and between dif-
ferent healthcare providers. Participants reported
suffering from treatment effects, high costs, worry,
and inconvenience from what they perceived to be
overuse. They suggested that overuse may be re-
duced when the patient is involved in decision mak-
ing and has a trusted primary care doctor.
lights potential sites of intervention to reduce
healthcare overuse. Engaging patients in shared
decision making and enhancing communication and
knowledge transfer should be tested as interventions
to reduce perceived overuse.
KEY WORDS: healthcare overuse; older adults; qualitative research.
J Gen Intern Med 33(6):892–7
© Society of General Internal Medicine 2017
he continued growth in healthcare spending in the United
States is unsustainable.
Moreover, spending is not cor-
related with indicators of high-quality care.
between costs and health outcomes has led many to conclude
that healthcare services are overused in the U.S.
Healthcare overuse has been defined as the provision of
care in circumstances where the potential for harm exceeds
the potential for benefit.
Excess use of health services puts
patients at risk of adverse outcomes
and creates system-
Overuse is pervasive within the healthcare
system, and is a target of recent efforts such as the Choosing
Wisely campaign of the American Board of Internal Medicine
(ABIM) Foundation. We suggest that older Americans may
be particularly vulnerable to this phenomenon. Examples of
overuse include cancer screening tests in patients with limited
treatments delivered at end of life that do
not impact disease course or quality of life,
ered without recognition of the heterogeneity among older
polypharmacy in multimorbid older patients,
care coordination failures when multiple specialists are in-
Given that the harms and benefits of interventions
are often unclear, and patients are frequently unaware of these
trade-offs, their perceptions of what constitutes overuse may
differ from what clinicians or professional societies define as
We were interested in learning whether older adults per-
ceive that there is overuse of healthcare services and whether
they view it as problematic. Our goal was to illuminate the
perspectives of older adults as a necessary first step to
informing a framework for understanding, and ultimately re-
ducing, healthcare overuse in older adults.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11606-017-4264-y) contains supplementary
material, which is available to authorized users.
Received June 26, 2017
Revised October 12, 2017
Accepted December 4, 2017
Published online January 3, 2018