Monday, 6 March 2017

Right Care: definition, gray areas and reversals

One of the Right Care Alliance initiatives, led by Vikas Saini and Shannon Brownlee from the Lown Institute in Boston, has been the compiling of 4 reports that are analyzing the misuse, by excess and by default, of health resources from a global perspective.

What does the Lown Institute mean by "right care"?

Before defining the concept of "right care", we must take note of Donald Berwick's definition of quality in the introductory article of the series. The author believes that the quality of care, as we understand it, is too focused on the guarantee of procedures and, despite being correct, the question now is: what do the inappropriate clinical processes mean for people’s health? Berwick states that quality should be understood as the provision of services that respond to people's real needs. So, practically, appropriatness has been filtered in the realm of quality.

Along the same lines, Sabinet Kleinet and Richard Horton, editors of the Lancet, have developed the following definition of "right care": health care that provides more benefits than unwanted effects, taking into account the circumstances of each patient, and their values and their wishes into account; in addition the right care is based on the best available evidence and on cost-effectiveness studies.

Having established a definition is a first step, but that does not mean that the difficulties that follow are not huge. To begin with, quantifying undesirable benefits and undesirable effects is often very difficult because the evidence is often incomplete and the iatrogenic is poorly documented; moreover the threshold between appropriate and inappropriate is usually a gradient, and can vary among people, among different cultures and between different countries.

If at the extreme right we represent the totally appropriate actions (insulin for type 1 diabetes) and at the extreme left, the clearly inappropriate actions (antibiotics for viral diseases), in the middle there is a grid of gray areas that include services that bring very (glucosamine for osteoarthritis), or that the balance between good and bad effects varies from individual to individual (antidepressants for teenagers) or routines that are not emerged from any proven evidence (analytical controls for hypertensive patients).

Many clinical practices of wide use in the past (bloodletting, lobotomies, hysterectomies, tonsillectomies, radical mastectomies, hormonal treatments for menopause, etc.) had to be abandoned when the benefits they brought were contrasted with the problems they caused. Ian Harris, in "Surgery: The Ultimate Placebo," explains that he found that half of the surgical operations of the trauma departments of three Sydney Teaching Hospitals were not supported by consistent evaluations.

The reversal of low value clinical practices

Vinay Prasad published a review in Mayo Clinic Proceedings that detected 146 practices that should be reversed because the research had shown that they did not provide enough value. The reality, however, is stubborn, and when an activity is already implemented and has achieved a certain predicament, it can take many years to stop it, despite having all the evidence against it. There are some examples of how difficult is to reverse such as; the amigdalectomy in children or preventive angioplasty for unsealed coronary arteries. For this reason, Harris claims that, before their launch, the new diagnostic tests, the new surgical procedures and the advances in robotics must undergo tests of efficiency, at least of the same rigor as those of the new drugs, with the precise aim of avoiding a loss of objectivity caused by the admiration for the novelty and thus to prevent resistance before the necessity of an eventual reversion.

The "right care" thinking moves into a territory where gray areas predominate. It’s striking to see that, after twenty-five years from the emergence of evidence-based medicine, half or more of the clinical practices have not yet been sufficiently and rigorously assessed, while, paradoxically, the great bulk of research resources are obsessively aimed at assessing the effectiveness of the new drugs. 

Jordi Varela


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