Monday, 30 June 2014

Clinical practices that don't add value

The initiatives that warn of clinical practices that don’t add value or that contributes very little, are an advanced product of evidence-based medicine. This culture, which has the force of reason, often conflicts with several limitations to influence the actual practice of medicine. The first lies in the ‘original sin’, since most clinical trials leave out the very elderly and the multi-pathologies, the second has to do with the difficulties of adapting clinical practice guidelines to the actual circumstances surrounding each patient and the third is the influence of other factors, such as industry or popular culture, for example, when it comes to influencing clinical decisions.

This matter of little practical value is one of the most unclear of which I have addressed on the blog, and so I want to explain my opinion of the three main sources that today feed us information.

"Do not do” recommendations from NICE

This initiative stems from the futility that NICE experts have made of their own clinical practice guidelines. This is a list of quiet thousand recommendations including all specialties. Clearly they aren’t prohibited, but instead the prestigious agency experts warn that these practices don’t have sufficient scientific support.

To illustrate how these recommendations work, I have chosen five examples of the questions that NICE believes should not be posed:
  • Indicate hysterectomy as a first choice in cases of even strong bleeding
  • Prescribe antipyretics to prevent febrile seizures
  • Prescribe bevacizumab as first line in cases of metastatic colorectal cancer
  • Shaving the skin in surgical preparation
  • Hospitalising women with gestational hypertension

Choosing Wisely ABIM Foundation

ABIM is a private U.S. foundation that, as stated on their website, their mission is to promote professionalism among physicians. Choosing Wisely is an initiative of the foundation to support doctors who want to reduce the overuse of tests and procedures, and it also aims to help patients choose their options intelligently and effectively.

Choosing Wisely asks the scientific societies to focus on decisions for their clinical specialty that, in their view, both doctors and patients should question. Let's look at five examples of actions that, according to Choosing Wisely, are best avoided:
  • Performing electrocardiograms, or other heart tests, for people of low cardiac risk without symptoms (American Academy of Family Physician)
  • Performing electroencephalograms for headaches (American Academy of Neurology)
  • Taking advantage of the post infarction cardiac catheterization to implant stents in arteries that have not been responsible for ischemia (American College of Cardiology)
  • Using biomarkers, or PET, or CT, or radionuclide bone scans in the staging in asymptomatic women who had been treated for breast cancer with curative intent (American Society of Clinical Oncology)
  • Recommend feeding through some type of tube in patients with advanced dementia (American Academy of Hospice and Palliative Medicine)
Don’t miss the video where Dr. Christine Cassel, President of the ABIM Foundation and Mr. Jim Guest, president of Consumer Reports, explains the scope of "Choosing Wisely", regarding the support they give to doctors and the patients.

Project "Essencial" AQuAS

The "Agència de Qualitat i Avaluació Sanitàries de Catalunya” (AQuAS) recently released the project "Essencial", an initiative midway between NICE and ABIM, in the sense that while the project is under the "Agència" the institution is willing to seek the endorsement of scientific societies. On the AQuAS website you may consult the published recommendations, with a commitment from the contributors to offer regular updates and extensions.

Let’s look at a selection of three clinical activities that both the "Agència" and the relevant scientific societies believe lacks enough scientific support to advise their practice:
  • Continue recovering stroke patients beyond 12 months (with the support of the Catalan Society of Neurology)
  • Perform image tests in patients with lumbago during the first 6 weeks in the absence of warning signs (with the support of the Catalan Society of Radiology and Diagnostic Imaging)
  • Prescribe inhibitors of the proton pump in multi medicated patients or over 65 not receiving anti-inflammatory non-steroidal.


It is curious to compare the three sources cited above to see the different policy recommendations aimed at reducing clinical practices that don’t add value or that contributes very little.

NICE has developed and maintains an extensive list of recommendations from academic evidence, and takes advantage of their official stamp (and its own prestige) to send a clear message: "don’t do it."

ABIM, from an independent position, has determined that the scientific societies themselves are the ones who should take action on the matter. Therefore their recommendations have, in addition to the strength of the evidence, the support of the professional associations. By contrast, the final product is uneven, and while some scientific societies are merely getting wet, others simply sail. I guess you will not have missed the subtlety of the Americans when titling a negative phenomenon, with a clearly positive slogan: "Choosing Wisely", very different from the English approach.

AQuAS, in its turn, leverages the previous work of the two initiatives mentioned, but also works through the proposals with expert groups and scientific societies. Thus we see how some of its first recommendations are brave enough, and if you consult their website you’ll see that they provide explanatory text with data and indicators for subsequent evaluations, and that really is a unique approach by "Essential" because the English and American initiatives aren’t showing any assessment intentionality.

In my opinion these lists of clinical practices that add little value are valuable instruments for improving clinical effectiveness, but without internal work in each professional group and without evaluative adjustments in the payment models, I anticipate that progress will be limited.

Jordi Varela

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