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

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.

The cost/effectiveness of successful clinical actions

In this second post I want to talk about health care that is considered to be truly effective, despite the fact that it should be noted that there are effective actions not without controversy in their application in the community. At this point I think it’s appropriate to introduce a metric known as QALY (Quality Adjusted Life Year).

What is a QALY?

A QALY is a unit that measures the cost attributable for each year of added life that healthcare intervention is supposed to bring. In the NICE website (National Health and Clinical Excellence, a English National Health Service Agency which supports the health system to provide the best possible care with the best available evidence) there is a suitable explanation for non-epidemiologists on how to calculate a QALY.

How a QALY is calculated Patient x has a serious, life-threatening condition. • If he continues receiving standard treatment he will live for 1 year and his quality of   life will be 0.4 (0 or below = worst possible health, 1= best possible health) • If he receives the new drug he will live for 1 year 3 months (1.25 years),    with a quality of life of 0.6.  The new treatment is compared with standard care in terms of the QALYs gained: • Standard treatment: 1 (year's extra life) x 0.4 = 0.4 QALY • New treatment: 1.25 (1 year, 3 months extra life) x 0.6 = 0.75 QALY   Therefore, the new treatment leads to 0.35 additional QALYs   (that is: 0.75 -0.4 QALY = 0.35 QALYs). • The cost of the new drug is assumed to be £10,000, standard treatment costs £3000.   The difference in treatment costs (£7000) is divided by the QALYs gained (0.35) to      calculate the cost  per QALY. So the  new treatment would cost £20,000 per QALY.

I think the NICE explanation is very educational (in fact I haven’t found a better one) and can be a good reminder for everyone.