Friday, 21 February 2014

"The Surgical Signature" and how the patients can influence the overtreatment

In his latest book, Tracking Medicine, presented in the first post of this blog, Wennberg says that it’s possible to recognize a hospital by their rates of interventions profile (population-based) from a small handful of surgical procedures. And he demonstrates it with the following graph:

The analysis of the 5 selected areas in this 1975 work shows the profile of five surgical procedures ("The Surgical Signature") of each of them. So you can see that the men of Portland have the highest probability of the series to be undergoing prostatectomy (50% above the average), while citizens of the same Portland, in general, have the lower odds of having haemorrhoidectomy (40% below the average), Lewiston women face the highest rates of hysterectomy (60% above), in Augusta the average varicose extractions doubles, Waterville is the champion in operating haemorrhoids (nearly triples average) and finally the Bangor area is only notable for having the lowest rates of prostatectomy’s series.

The paper concludes that variations in the use of surgical resources are observed not only in comparisons between systems (see previous post) but also, the phenomenon has a land mark that does not correspond with the socio-demographic characteristics (which are adjusted) nor with the prevalence of diseases susceptible to surgical intervention.

Another finding of these authors is that these territorial surgical profiles, which are presumably related with the criteria of doctors who work there, are also persistent long term. Next, take a look at the figure below showing the two graphs that are comparing rates of hip and knee prosthesis of a large number of regional areas in the United States, between 1996 and 2005. At a glance it’s clear that during that decade the observed rates have not only increased in general, but with a correlation of 0.72 for hip and 0.70 for knee, the values ​​of these rates has been maintained, after ten years with the same profile: the areas where they operated less continues have low intervention rates and vice versa, and also the differences between areas that can go as far as tripling its values ​​when the most consuming are compared with the less consuming ones, remain unchanged.

The medicine based on patient preferences order to mitigate such arbitrariness in the medical opinion, in the early '80s in the United States, an initiative was born that led to the creation of the "Informed Medical Decision Making Foundation" and immediately was obvious that, when patients diagnosed with a pathology susceptible to surgery, received an independent evidence-based information and shared focus groups with other patients who had already gone through the same, the non-surgical options gained prominence and patients showed greater involvement and satisfaction with the process.

The materials that the Foundation are making available to patients must be specifically asked for, but if you are interested you can click the video collection available on the IMD Foundation's Channel.

Also it’s worth taking a look at the services and products for patients’ support offered by the not profit company Healthwise. This company was established in 1975 and its mission is to help people make decisions that affect their health.

In this review we should also mention the efforts of the English National Health Service through "NHS Direct Decisions Aids" program:

Cochrane Collaboration, in a review of 2011 based on 86 clinical trials (Stacey D, Bennett CL, Barry MJ et al. (2011), "Decision aids for people facing health treatment or screening decisions". (Cochrane Database Syst Rev (3): CD001431. DOI: 10.1002/14651858.CD001431.pub3. PMID 19588325), concludes that programs to support patients for decision-making, both in treatment and preventive interventions, provide better results than traditional systems (doctor-patient only), in terms of:
  • More and better knowledge of the process by the patient.
  • Less conflicts due to deficiencies in the information received.
  • Less conflicts due to the lack of consideration of the patient’s values ​​and beliefs.
  • More participation and involvement from the patient
And as for the health system and its budgetary constraints, a very interesting fact of this Cochrane review, which was already seen in previous reviews, is that these decisions support programs aimed directly at patients reduce surgical intervention in favour of more conservative options. Even some work on specific pathologies concludes that these reductions can be 20% or higher (Mulley 2012 recommended bibliography).

That's all for today's post about how patients may partly make up for the high doctors’ arbitrariness with regards to surgical indications, that may also benefit of other approaches (which can sometimes be ‘do nothing at all’).

Recommended Bibliography on the medicine based on patient preferences:

Jordi Varela

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