Lessons from the opioid crisis, a case of overtreatment with devastating consequences

Cristina Roure
 

If you are regulars of American series such as House, The Affair or This is us, you will be familiar with the classic protagonist who, after an episode of acute pain, ends up becoming addicted to prescription opioids such as Vicodin®, OxyContin® or Percocet®. Do not think that this is a writer’s exaggeration.

In 2015, life expectancy in the United States changed the trend and began to decline for the first time since the First World War. Among the causes, the epidemic of deaths from opioid overdoses, which multiplied by six between 1999 and 2017 (1), surpassing deaths associated with AIDS at its worst or those related to the Vietnam War. The epidemic was declared a national emergency by the United States Department of Health in 2017 and, despite the campaign deployed to combat it (2), 130 people still die in that country every day from opium overdose. If you are interested in the subject and want to delve into it, read the supplement that Nature dedicated to it in September last year.

The topography of overuse

Andreu Segura

More and more voices warn about the damages associated with the excessive use of health services, although those who claim for the negative consequences attributable to precariousness and the cuts suffered by public health still prevail.

Of course, some protests as well maybe relevant since the health damages related to medical and health care are a consequence of both the action and the omission. And it isn't strange that both coexist because, for example, the abuse of imaging tests leads to an increase in the waiting list of patients who are candidates for exploration, so that the higher the proportion of superfluous prescriptions, the more they will be delayed those that are necessary, those whose result can modify the clinical decision for the benefit of the patient.

New diseases: new?

Ways of expanding disease definitions: promoting awareness about pre-diseases, & early and ↓ thresholds of diagnosis http://t.co/Xne8Xb2l1V
— Enrique Gavilán (@enriquegavilan) August 14, 2013

Enrique Gavilán is a family physician who has a habit of providing good professional quality "material" on Twitter, especially with regards to evidence in overdiagnosis and overtreatment.

On this occasion, I have chosen a tweet from Dr Gavilán which refers to a work published in "PLOS Medicine" that analyzes 16 studies where there have been criteria changes in the diagnostic definitions of common diseases such as: hypertension, asthma, attention deficit hyperactivity disorder (ADHD), COPD and dementia, among others.

One finding of the study was that these changes in criteria were mainly in three directions: creation of pre-conditions, lowering superior analytical values ​​and introduction of methods of early diagnosis. Another discovery is that these changes in criteria, which only serve to increase the legion of people affected by supposedly pathological conditions, are not accompanied by evaluations of the negative or even harmful impact to the health of "new patients". And there's a final finding: many of these studies have been developed by researchers with an economic interest linked to pharmaceutical companies directly involved in the proposed criteria changes.


Jordi Varela
Editor

End of Life Overtreatment: Hospital Care Intensity (HCI) Index

Hospital Care Intensity (HCI) Index is a summary measure of the intensity of hospital resource consumption that is constructed, starting from the number of hospital stays and the number of visits to a specialist. Through this index, created by The Dartmouth Atlas, John Wennberg discusses the use of hospital services series by chronic patients for the last two years of their life, and notices a change in HCI up to 4 times between regions with more extreme data: New Jersey (NJ) and Salt Lake City (SLC).

HCI last two years of life in patients with chronic

The healthcare systems are all clear that if an 80 year old lady’s femur breaks she should be operated. After the intervention, she’ll have more or less successful results and this will determine the functional recovery of the patient, the permanent disability, or the death. But instead, when a patient with one or more chronic diseases grows older and his chronic diseases multiply or aggravate, then the response of almost all the systems is to provide disproportionate and costly hospital services, but all very uneven, as seen in the table above.

"The Surgical Signature" and how the patients can influence the overtreatment

In his latest book, Tracking Medicine, presented in the first post of this blog, Wennberg says that it’s possible to recognize a hospital by their rates of interventions profile (population-based) from a small handful of surgical procedures. And he demonstrates it with the following graph:

The analysis of the 5 selected areas in this 1975 work shows the profile of five surgical procedures ("The Surgical Signature") of each of them. So you can see that the men of Portland have the highest probability of the series to be undergoing prostatectomy (50% above the average), while citizens of the same Portland, in general, have the lower odds of having haemorrhoidectomy (40% below the average), Lewiston women face the highest rates of hysterectomy (60% above), in Augusta the average varicose extractions doubles, Waterville is the champion in operating haemorrhoids (nearly triples average) and finally the Bangor area is only notable for having the lowest rates of prostatectomy’s series.

The paper concludes that variations in the use of surgical resources are observed not only in comparisons between systems (see previous post) but also, the phenomenon has a land mark that does not correspond with the socio-demographic characteristics (which are adjusted) nor with the prevalence of diseases susceptible to surgical intervention.