Rational decision making in medicine: Implications for overuse and underuse

Benjamin Djulbegovic, Shira Elqayam, William Dale
2017 Journal of Evaluation In Clinical Practice  
In spite of substantial spending and resource utilization, today's health care remains characterized by poor outcomes, largely due to overuse (overtesting/overtreatment) or underuse (undertesting/undertreatment) of health services. To a significant extent, this is a consequence of low-quality decision making that appears to violate various rationality criteria. Such suboptimal decision making is considered a leading cause of death and is responsible for more than 80% of health expenses. In this
more » ... paper, we address the issue of overuse or underuse of health care interventions from the perspective of rational choice theory. We show that what is considered rational under one decision theory may not be considered rational under a different theory. We posit that the questions and concerns regarding both underuse and overuse have to be addressed within a specific theoretical framework. The applicable rationality criterion, and thus the "appropriateness" of health care delivery choices, depends on theory selection that is appropriate to specific clinical situations. We provide a number of illustrations showing how the choice of theoretical framework influences both our policy and individual decision making. We also highlight the practical implications of our analysis for the current efforts to measure the quality of care and link such measurements to the financing of health care services. KEYWORDS clinical decision making, health policy, overtreatment, overuse, practice, rationality, undertreatment, underuse 1 | INTRODUCTION It is no secret that today's health care system is in crisis 1,2 : Societies devote a substantial amount of resources to health care, and yet patient outcomes remain inferior. The United States alone spends nearly 18% ($3.2 trillion) of its gross domestic product on health care; however, only 55% of needed services are delivered and more than 30% is inappropriate and, therefore wasteful, "care." 3 Ultimately, the observed (suboptimal) care relates to the quality of medical decisions. 3 Indeed, it has been contended that personal decisions are the leading cause of death 4 and that physicians' decisions are responsible for 80% of health care expenditures. 5,6 If decision making can largely explain the relatively poor state of affairs of current health care utilization, the logical question to ask is as follows: Are the decisions made during doctor-patient encounters, in fact, rational? In a recent paper, we reviewed existing theories of rationality and their implications for medical practice. 7 We found that no single model of rationality can fit all medical contexts; what is considered "rational behaviour" under one rationality theory may be considered "irrational" under another one. 7 We call this "normative pluralism," which, as explained in detail below, calls for the matching of a given clinical situation/problem with a given theory of rationality. --- This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
doi:10.1111/jep.12851 pmid:29194876 pmcid:PMC6001794 fatcat:vrube5a26zdpfec2bnxxfm57ya