Monday, 28 July 2014

Less is more: "Overtreated" by Shannon Brownlee








The campaign "Too much medicine" by the British Medical Journal wants to highlight the threat of over diagnosis to the health of individuals, and also expose the inherent waste of resources involved in inappropriate clinical practice. According to the BMJ, there is evidence that more and more people suffer from over diagnosis and overtreatment for a wide range of clinical circumstances such as cases of asthma, chronic renal failure or prostate and thyroid cancer. Through this campaign, the magazine plans to improve awareness among physicians of both the benefits and side effects of treatments and technologies, and thus find out how excesses can be reduced safely and properly.

The editor of the BMJ, Fiona Godlee, gives much attention to the campaign: “As medicine based on evidence, or clinical safety, were the movements of the previous decades, combating excess is a contemporary manifestation of an ancient desire: no harm when we want to heal".

To start talking about this campaign, I thought it would be appropriate to review the book “Overtreated" whose author, Shannon Brownlee is a science journalist who has published in Atlantic Monthly, New York Times, New Republic and Time.

Too much medicine

This is the title of the first chapter of the book, where she writes: “As most clinical practices have never been scientifically proven, when someone was faced with them, it turned out that many of them did not offer a good balance between damage and benefits, they only believed it and let’s review some clinical activities that, having had their base in the moment that have been evaluated, had to be rethought seriously such as tonsillectomies, hysterectomies, frontal lobotomies, radical mastectomies, arthroscopies knee arthritis, radiological screening for lung cancer, inhibitors of proton pump for stomach ulcers, menopause hormone therapy, high-dose chemotherapy for breast cancer, etc."



A dangerous place

Elliot Fisher, a John Wennberg's collaborator, illustrates this chapter of the book, intended to show how dangerous excessive health activity can be:
  • The patients seen in expensive hospitals are between 2 and 6 percent more likely to die.
  • When compared with adjusted data, different territories, the probability of death is higher in places with greater health spending.
  • Fewer specialists and more family doctors is equivalent to better health outcomes.
  • The most consuming regions of health services aren’t offering better care, ever more responsive to the needs, they simply spend more.

Money, Drugs and Lies

According to the author of the book, if one wants to practice medicine based on the evaluation models, one must change research funding. David Eddy, a heart surgeon, mathematician and economist says in this chapter that only 15% of clinical practice has sufficient scientific support, and to demonstrate it, he gives some examples: how can we know what is the best treatment for chronic sinusitis, what scientific basis fertility treatments have or what relationship exists between foetal monitoring and increase in caesarean sections.



CARE strategy

And to end, I present the Brownlee recipe called CARE, an acronym for: Coordination, Accountability, Electronic medical records, Evidence. As a base for the recipe, the author relies on the developments that have made ​​the VHA (Veterans Administration), that went from being a bureaucratic system to an integrated service model that is in line with the best such as Kaiser and Mayo. For Brownlee, the recommendations for reducing overtreatment go through strategies already tested by VHA:
  • Implement the same clinical history models in all corners of the organisation.
  • Reduce excess hospital beds and excess specialists, which are the main reasons for health overacting.
  • Be sure that primary care has time and resources to perform well, both at the community level and in the implementation of preventive activities.
  • Ensure good coordination between levels of care.
  • Ensure transparency for the management and clinical quality of results,
  • Promoting evidence-based activity.

Discussion

As we were already warned by John Wennberg, the installed capacity is much heavier than we thought, and when comparisons between areas of health consumption are observed, this is the most important factor. If there is a bed, it will be filled, if there are operating rooms, surgery will be performed. As seen in the previous period, when there was investment in health we did not know how to harmonise the flow of money with the necessary adjustment of clinical activities to the strictly necessary. And now, although we don’t like it, we are forced to fight waste and for the sake of the sick, we’d better do it with clinical judgment.



Jordi Varela
Editor

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