When less is more: a strategic agenda

When Less Is More: Issues Of Overuse In Health Care – Health Affairs Blog http://t.co/9BabaZFFUY

— Joan Figueres Sendra (@joan_figueres) April 26, 2014

Dr. Joan Figueres, expert in the evaluation of health services, announces with his tweet, of the publication of a post signed by Shannon Brownlee and Vikas Saini, Vice President and respectively President of Lown Institute, along with Christine Cassel, President of ABIM Foundation. This post was published on the blog of Health Affairs on 25 April and in total agreement with Dr. Figueres, I also find it remarkable as I believe that the article does a good overview of the current grade of clinical waste outbreaks and suggests some strategies for engaging physicians, patients and the media in improving the situation, and I will focus on the latter:

The parsimonious medicine

I started the last Mondays’ post with the "Too much medicine" campaign from the British Medical Journal but in this one I want to talk about the "Less is more" article from "JAMA Internal Medicine" that began in April 2010 with the aim of bringing to our attention the side effects of diagnostic tests and treatments that from the outset are not expected to add any value.

Parsimonious medicine versus spending cuts

Dr. Jon Tilburt, an internist and researcher in biomedical ethics at the Mayo Clinic, and Dr. Christine Cassel, president of ABIM Foundation (see the Video that presents the "Choosing Wisely” campaign), in an article published in JAMA, attempt to differentiate between the ethics of "no budget and therefore I can’t request a test" and those of "this test does not suit you, it will not contribute anything new to what we already know, and additionally, the test itself carries risks that do not outweigh the expected benefits". According to the authors, as at the moment the two ethics are competing on the same stage, an effort must be made to explain them better from a professional point of view. 

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