SHM Converge Scientific Abstract ePoster Gallery-Reducing Overuse by Healthcare Systems: A Positive Deviance Analysis

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This study examined why some “positive deviant” healthcare systems have much lower-than-average overuse of low-value services while still delivering high-quality care. Researchers identified 30 systems using an Overuse Index and confirmed quality using CMS Hospital Compare data; 10 systems agreed to participate. They conducted semi-structured interviews with executive leaders, then used qualitative content analysis to identify themes.<br /><br />The findings largely supported the Morgan framework on overuse, especially the importance of the patient-clinician interaction. Interviewees emphasized that overuse is reduced when patients trust clinicians, are open to discussion about why tests or treatments are not needed, and value affordability alongside quality. Clinicians in these systems often shared beliefs that low-value care does not help patients and described a strong culture of “doing the right thing,” continuous learning, and small tests of change.<br /><br />A notable additional theme was financial structure. Leaders said that payer mix, employer pressure, and alternative payment models strongly influence the ability to avoid overuse. In fee-for-service settings, reducing unnecessary care can mean losing revenue, whereas bundled payments, HMOs, and other value-based arrangements better support high-value care.<br /><br />The study concludes that both clinician/patient culture and financial incentives help explain why some health systems successfully reduce overuse. It suggests that existing frameworks should explicitly include economic and payment-related factors. Limitations included a low response rate and a sample skewed toward systems with safety net hospitals.

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Author List Michael I. Ellenbogen, Aaron Wiegand, Matthew Austin, Nancy Schoenborn, Nihal Kodavarti, Jodi Segal

Category Research

Concept Positive Deviance

Concept Overuse Index

Concept Low-Value Care

Concept Overuse

Concept Overutilization

Distinguished Non-Finalist

Presenter Organization Johns Hopkins School of Medicine

Presenting Author Michael I. Ellenbogen

Track Other

Keywords

overuse

low-value care

healthcare systems

patient-clinician interaction

quality of care

financial incentives

value-based payment

semi-structured interviews

qualitative content analysis

positive deviance

Positive Deviance

Overuse Index

Low-Value Care

Overuse

Overutilization