Monday, 13 March 2017

Right Care: between too much and too little

In the "Right Care" series of the Lancet magazine, Donald Berwick, in "Avoiding overuse - the next quality frontier", says that inappropriate clinical practices consume between 25% and 33% of health budgets in all countries in the world, but beyond the staggering amount of so much wasted money, there are four characteristics of excess, which Berwick emphasises: a) they affect the full range of health services and all specialties, although unevenly; b) there are specific clinical processes where exaggeration is highly disproportionate; (c) they are not exclusive to rich countries being also found in developing countries and in poor countries, in the latter group still with some dramatic traits, and d) are not related to the greater consumption of resources, since wastage can also be found in areas with less frequencies. 

Some figures of world-wide overuse

In direct observation studies in the first report of the "Right Care" series, it’s estimated that 57% of the antibiotics consumed in China should not have been prescribed, that between 16% and 70% of US hysterectomies are not justified, that 26% of knee arthroplasties in Spain could have been avoided and that 30% of coronary angiographies performed in Italy should not have been indicated. To end this compilation, it’s estimated that there are 6.2 million caesarean sections in excess in the world, half of them in Brazil and China.

Another group of figures that offer an indirect measure of overuse are those from atlases of variations in clinical practice. To give three examples: a) the incidence of arthroscopies observes a variation of up to 13 times between different territories within England; b) elective angioplasties, up to 10 times in an internal analysis in California; and c) the Spanish average of potentially preventable hospitalizations (ambulatory care sensitive conditions) is 60 per 10,000 inhabitants over 40 years, with a coefficient of variation between territories in which the highest figures triple the most moderate (see HPE VPM atlas).

Barriers to access to appropriate clinical practices (underuse)

The other side of the coin is represented by those circumstances in which appropriate clinical action does not reach its intended recipient. In this sense, it’s not enough to offer explanations in a world where 1.5 million children die of vaccine-preventable diseases every year. That said, I found it interesting to highlight the following chart in the second report of the "Right Care" series, which divides gaps in appropriate reception of health services into 4 categories: a) lack of access (400 million people in the world don’t have access to basic health services b) lack of resources (86% of people in sub - Saharan Africa who would need surgery don’t have access to any surgeons nor to any operating rooms), c) a lack of proven evidence (43% 45% of the worldwide consultations don’t provide scientifically proven services); and d) lack of adherence (26%-42% of people who have had a heart attack don’t follow the medical recommendations).

Key messages (overuse & underuse)

a) Overuse of healthcare activities of little value and, on the other hand, barriers to benefit from clinically effective practices are aspects that coexist in all countries and cause avoidable suffering to millions of people around the world, as well as inappropriate and unjust resources.

b) Access to health services is a human right and governments should therefore ensure their sustainable universal coverage (within their means). The struggle, both against overuse and against lack of access, is a matter of social and political ethics.

c) Much more research funding should be devoted to the evaluation of clinical practices that don’t yet have sufficient evidence support, in order to reduce, as far as possible, gray areas of medical activity.

Jordi Varela

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