Case conference with Dr. Don’t

4. July 2013
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Which medical measures are not appropriate for a given symptom? In the U.S., negative lists have now been created, which include items which doctors and patients should refrain from using "too much". In other countries as well there is interest in this approach.

“It does not make sense to initiate a natural delivery or a Caesarean operation before the 39th week of gestation”. “Children under four years of age should not be given cold remedies”. “Contrary to the habit of many patients and doctors, in many treatments the associated risk or harm outweighs the benefits”. “More is better” and “Expensive is better”. These wisdoms are still widely spread among patients. Yet at the same time a survey of 18,000 citizens done for the Health Monitor 2011 of the Bertelsmann Foundation has presented a bleak picture for independent physicians: 90 per cent of participants believe that physicians provide unnecessary and redundant services, some of them very often.

700 billion dollars of “waste”

There is no doubt that billions of dollars used in health services could be saved if the patient and the doctor would limit themselves to what is necessary and sensible. This applies to Germany, but especially to the U.S. where a figure in the area of $ 700 billion of “waste” is produced there as well.  A third of the services are unnecessary, one sixth of them unsatisfactorily carried out, says one set of statistics, a quarter of the regulations are associated with an overly large bureaucracy. There are therefore ever more urgent demands being made for participatory decision making – after joint consultation involving doctor and patient. Explaining and using alternatives to the usual, expensive treatments associated with multiple testing and treatments use would reduce costs significantly.

135 times “Do not …”

“Choosing Wisely” is a joint initiative of a large consumer organisation (Consumer Reports) and the ABIM, American Board of Internal Medicine, a non-profit organisation for the promotion of medical professionalism. At this point in time, 42 professional societies from among the various medical specialisations have joined the action. About a year ago initiator Howard Brody prompted the affiliated organisations to name five tests or treatment agents which – when prescribed unnecessarily – harm the patient and usually also cause increased costs. If a test for verification of a diagnosis is available, many doctors do not hesitate to prescribe it – often also for asymptomatic patients who do not show indications for the respective medical condition attached to the examination. By spring this year this list had grown to an impressive 135 points.

In the instance of a short bout of unconsciousness, neither a CT nor a Nuclear Magnetic Recording are needed. For children with minor head injury, the head should then only be X-rayed when it is absolutely necessary. An Exercise ECG is unnecessary in patients without symptoms and low risk for heart disease. These and other recommendations are now available on Choosingwisely.org, alongside the appropriate background information, to both doctors and to those being treated. The initiators themselves probably did not expect such a great response to their efforts, which should also serve to improve communication between doctor and patient, and to initiate the discussion about necessary and unnecessary therapies. Already in the preparation of “Choosing Wisely”, an analysis of the National Physicians Alliance in 2011 indicates a saving of about $ 5 billion in such “top 5” lists.

Do guidelines suffice?

This success with respect to doctor (and patient) advice has now spread right to the other side of the Atlantic. Could “Choosing Wisely Germany” become for us in Germany a totally successful model in health insurance terms, as well as for the patient? Or is it just “old wine in old bottles,” because Germany’s strategy, with guidelines on the treatment of many diseases, is frequently already more advanced than in the U.S.? At a workshop run in March of this year prior to the annual meeting of the evidence-based medicine network, this was discussed by renowned experts from various disciplines.

Günter Ollenschläger, Head of AQuMed (Doctors’ Agency for Quality in Medicine), reported on a study in which his fellow medical colleagues studied the guidelines for negative recommendations (Dont’s). Depending on the field, the relative number of pieces of advice relating to the omission of procedures is quite variable. Many references to unnecessary or harmful steps can be found in the treatment of non-specific low back pain or when using hormone therapy in menopause. In contrast, there are few measures against which the authors advise within the guidelines on rheumatoid arthritis or juvenile diabetes. Similar to the U.S. based “Choosing Wisely”, the German national guidelines on back pain recommends carrying out no imaging procedures for acute complaints without evidence of dangerous complications. Overall, concludes Ollenschläger in his presentation, recommendations against certain treatments or medications are often already integrated in the German guidelines.

Prioritisation without rationing?

There was criticism often made in the discussion that the recommendations in “Choosing Wisely” are partly inconsistent and opaque. Thus, the five points set by the American clinical oncology group are based on a literature search and a subsequent discussion with experts, oncology associations, self-help groups and leading doctors. Ultimately, a committee of ASCO adopted the advice. Instead, the radiologists, “leading doctors” and directors of various disciplines concluded their “top 5 list” without external guidance. Unanswered is the question of whether the other recommendations for physicians in the “guidelines” are equally important, or whether a “prioritisation without rationing” would not be the better way to make the most of a limited health budget. Nevertheless, Heiner Raspe, public health physician at the University of Lübeck, believes he would certainly support a German “Choosing Wisely” Initiative. This is a view that is shared by physicians in Germany’s national neighbourhood. “The list gives physicians and patients the necessary courage for once not to do something”, Bern-based Drahomir Aujestik of the Association of Swiss Internists adds in agreement with his colleagues.

No time for detailed explanations

But in practice old habits often resist new recommendations. With this in mind Craig Pollack of Johns Hopkins University in Baltimore examined how the behaviour of doctors changed after the negative outcome for the PSA test used for examinations of the prostate. 38 per cent of doctors surveyed would not change their current habits and continue to prescribe the PSA test. Only two per cent were willing to follow the recommendations unconditionally. Main reasons for the dismissive responses were the duty of doctors to justify their behaviour changes to the patients and the lack of time for explaining the new strategy.

On the patient side, the trust in one’s own doctor is very often greater than that held in the advice coming from some professional societies. Yet even on the doctor side of the matter the level of ignorance and sometimes distrust of control bodies such as the IQWiG (Institute for Quality and Efficiency in Health Care) or the German Federal Joint Committee is considerable, as the Deputy Chairman of DNEbM Daniel Strech described in a presentation at the annual meeting of the IQWiG referring to a survey.

“Shared Decision” Between Doctor and Patient

“Informed patients decide differently.” David Klemperer from the University of Regensburg thus pleads for the model “Shared Decision”, which also forms the basis of the “Choosing Wisely” movement. This requires from doctors not only an understanding of treatment guidelines, do’s and dont’s, but also more attention and time for the patient. It was supposed to be natural for them to clarify to those in their care the basis of their treatment suggestions. This is however, according to the survey done by Klemperer and his colleague Diercks for Health Monitor 2011, something performed by only a small number of doctors. And what’s more there are even fewer patients who inquire to their doctor about appropriate guidelines.

According to the ideas of the Network of Evidence-based Medicine, “Choosing Wisely” ought to become popular with us too – even if guideline authors have already achieved important groundwork. The results of the workshop will mark the path for further action. Applying all  due diligence to the establishment of guidelines based on study results, “omission lists” could lead to a change of consciousness among physicians as well as among patients. It’s not always so that “more of” or “more expensive” is the better alternative.

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