The risks of doing the wrong things

José Joaquín Mira
 

The New Yorker

In all disciplines, we find some questions in search of an answer that stands out above all other questions, but without finding an adequate solution. The correct treatment, for the right person and at the right time (therapeutic adequacy), is one of those holy grails that affect, in this case, health disciplines.

In search of the things we do without reason

Nacho Vallejo

In healthcare, there is usually a special appreciation for tradition or antiquity, which does not always translate into better clinical care. The reality is that there are things that we professionals do without the contrast of adequate evidence or, simply, without these actions providing sufficient value.

The Choosing Wisely initiative was launched a few years ago from a private North American institution. It was necessary to suggest to the scientific societies of that country the development of recommendations on clinical practices that both doctors and patients should rethink.

Medicine must be value-based

Paco Miralles

Many of us believe that medicine in general and doctors, in particular, should direct efforts to provide patients with value services. This approach would leave even the profane flabbergasted: but do doctors not do for their patients that which gives them value?

It's important to know the past to understand the present and outline the future. For a few decades, we have acted based on evidence-based medicine, a movement that led to the transition to a methodologically neater practice. Assistance based on tradition and empirical experience would succumb in the face of well-structured studies. This revolutionary concept led him to be nominated as one of the ideas of the year 2001 by The New York Times.

Please let me see my lifelong doctor

Paco Miralles

If you are a reader, likely, you will always go to the same hair salon, and surely you will like to be attended by your usual hairdresser. If you are male, you probably also appreciate finding a familiar face for cutting your hair, avoiding having to explain the type of cut you want every time. It’s even possible that on some occasion people delayed their visit a few days when they learn that the person who usually serves them is on holiday. This tendency is present in other sectors. We generally like our hair, our nails, our fish or our fruit to be dispensed by "our" trusted person and we are not often willing to change stores.

Recommendations against low value clinical practices. Are they useful?

As the Choosing Wisely campaign enters its final stages, Owen Dyer looks at whether it can change practice http://t.co/B8BfPvPdED
— The BMJ (@bmj_latest) October 4, 2013

Owen Dyer, a journalist and regular contributor to the British Medical Journal, following the Choosing Wisely campaign from the ABIM Foundation (a list of recommendations for clinical practice that both doctors and patients should question) in the US, makes an assessment of whether the lists of recommendations against low value clinical practices will manage to change the status quo or, on the contrary, the dynamics of the system will engulf them as it has done with many other initiatives.

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

The status quo bias

I like this JAMA (Volpp 2012) article because it raises the issue of the status quo and this is well-timed because just for now, we are accustomed to the debates on the introduction of new technologies or new drugs, and maybe that's why we’re now starting to evaluate the opportunity of innovation in terms of cost-efficiency or even cost-effectiveness. I’m talking about the $150,000 from the introduction of trastuzumab in metastatic cases of breast cancer per year of life gained, or the $370,000 of the use of erlotinib for advanced cancer of the pancreas cases (Weinstein 2010). But the question of the status quo is: are we wondering about the cost–effectiveness of clinical activities that are undertaken every day, or is that the status quo of having achieved a position in the portfolio of services, puts them at safety from doubts?

To illustrate the status quo, without going in-depth, I chose a couple of examples from the field of preventive activities and a couple more from the supposedly curative care activities.

Example 1 - PSA

Almost all health care assurances, both public and private, offer to men of 50 years of age, the opportunity to get an annual PSA test (Prostate Specific Antigen). It doesn’t seem to be a particularly expensive test, but now the controversy focuses on the disadvantages of early detection, because, according to experts, it’s not clear that this will bring more life to patients, but it does seem however, the resulting overtreatment can cause new problems in their daily life (incontinence, impotence). Expert groups claim to inform the men very well about all this prior to taking the test, but the assurances stubbornly continue to offer the annual PSA in its preventive portfolio without further consideration.

In case you are interested in this issue I offer the link to the U.S. National Cancer Institute.

Waste, the oncologists say

"In first world countries, cancer treatment has adopted a culture of excess: excess in diagnosis, excess in treatment, excess in promises"

The chosen title belongs to the report that “The Lancet Oncology Commission" published and which was signed by a large group of oncologists. In the excerpt below you can see on the right, the heading of the list of authors that extends over two pages.

This is an important document critically reviewing all aspects of approaching cancer in Western countries: the cost effectiveness, the use of technology, the mad race of the new drugs, the adequacy of the research, the role of medical oncology, the surgery, the radiotherapy, the genomics, the palliative, but mostly the question that the authors pose is whether the path followed by oncology is the most appropriate, and if as a society we can afford it.

Four ways to make Sutton’s law a reality

It occurs to me that there are four possible approaches to address Sutton's law (remember that this law tells us that we have to go after the waste to raise funds for activities that really provide a health value to people, see post March 28th) and I think we need the four approaches at once:

1. Medical service based on patient preference (see post February 27th)

There is a report from a Cochrane review that says that when patients have contrasting information, other than from their doctor, they have a tendency to choose more conservative therapies within the range that is offered with their diagnosis. And, according to some researchers, up to a 20% reduction in some scheduled surgical procedures can be expected with this method.

2. The role of scientific associations in addressing evidence-based medicine

The difficulties in the practice of medicine begin in the gap that exists between the scientific evidence and the reality of clinical practice. In this area there is a missing link that causes a striking variability in clinical practice and the utilization of health care resources. For this reason, in recent times interesting professional initiatives are being observed (which we will discuss further in later posts), of which highlight "Do not do" from NICE in the UK and "Choosing Wisely” from ABIM Foundation in USA.