October 30, 2017 | Author: Anonymous | Category: N/A
Too much medicine: why we need to push back the tide of medical excess. Dr Fiona Godlee, FRCP ......
Elizabeth Blackwell Annual Lecture
Too much medicine: why we need to push back the tide of medical excess Dr Fiona Godlee, FRCP, Editor-in-Chief, The BMJ 10 October 2016
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Too much medicine
Why we need to push back the tide of medical excess Elizabeth Blackwell Lecture October 10, 2016 Fiona Godlee The BMJ
Too much medicine comes from a combination of overdiagnosis and overtreatment These are clearly linked! Both can co-exist with underdiagnosis and undertreatment!
What is overdiagnosis and why drives it? Overdiagnosis occurs when a diagnosis is “correct” according to current professional standards but the diagnosis or associated treatment is unlikely to benefit the person Driven by -Increasingly sensitive tests finding things that didn’t need finding -Expanded definitions of disease/lowering of disease thresholds -Creation of pseudo-diseases (disease mongering) -Clinicians fear of missing a diagnosis, or of litigation -Public enthusiasm for screening -Policy maker/commercial enthusiasm for screening and prevention -Patients’ desire for testing for reassurance -Financial incentives
Incidence, mortality, and case fatality of pulmonary embolism in United States, 1993-2006.26.
Wiener R S et al. BMJ 2013;347:bmj.f3368
©2013 by British Medical Journal Publishing Group
Fig 2 Incidence of and mortality from thyroid cancer in the US, 1975-20093 and advent of new technologies.
Brito J P et al. BMJ 2013;347:bmj.f4706
©2013 by British Medical Journal Publishing Group
Clinical context—Up to 40% of adults worldwide have hypertension, complications of which may account for up to 9.4 million deaths annually from cardiovascular disease Diagnostic change—Recommendations for drug treatment have decreased from diastolic pressure of >115 mm Hg to ≥140/90 mm Hg. A new category, prehypertension (120/80-139/89 mm Hg), has also been introduced Rationale for change—Patients with even mildly raised blood pressure may have increased cardiovascular risk Leap of faith—Lowering threshold blood pressures will lead to increased diagnosis and treatment, which will decrease mortality
Impact on prevalence—22% of adults worldwide have mild hypertension (systolic pressure 140-159 mm Hg) and 13.5% have a systolic pressure ≥160 mm Hg Evidence of overdiagnosis—Use of a uniform threshold (140 mm Hg) to mark hypertension risk ignores evidence that risk varies by individual and includes many people who will not benefit from drug treatment Harms from overdiagnosis—Studies suggest over half of people with mild hypertension are treated with drugs even though this approach has not been proved to decrease mortality or morbidity. Overemphasis on drug treatment risks adverse effects, such as increased risk of falls, and misses opportunities to modify individual lifestyle choices and tackle lifestyle factors at a public health level Limitations of evidence — Lack of randomised trials that use hard outcomes and compare drugs with lifestyle interventions and placebo in patients with mild hypertension Conclusion—Lowering definitions of hypertension has led to identification and drug treatment of larger populations of patients despite lack of evidence that drugs reduce morbidity or mortality
Hersch J, Barratt A, Jansen J, et al. Lancet2015;385:164252.
Why does overdiagnosis matter?
“Too much testing of well people and not enough care for the sick worsens health inequalities and drains professionalism, harming both those who need treatment and those who don’t.” Margaret McCartney
“As a GP (and as a potential patient) I have a few unanswered questions. “Currently, around 11% of patients referred urgently with suspected cancer have the disease—that is, nine urgent referrals for one new case of cancer. If all GPs refer at 3% risk there will be 33 urgent referrals for each new case of cancer. As a patient, if I am investigated at a threshold of 11% risk I will have about six investigations (colonoscopies, prostatic biopsies, or the like) before I have a 50% chance of being diagnosed with cancer (0.896=0.5), whereas at a 3% threshold of risk I will be investigated 23 times. “I also face future risks from other cancers, arterial disease, neurodegenerative disease, chronic kidney disease, and so on. “One concern is that I will retire from general practice and spend my remaining years as a patient in hospital outpatient clinics.” Barraclough K. BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h3640 (Published 03 July 2015)Cite this as: BMJ 2015;351:h3640
From a talk by Victor Montori
Many reasons why physicians engage in overtesting and overtreatment. - perverse financial incentives -commercial marketing efforts designed to create demand for more testing, diagnosis, and treatment - fear of legal (malpractice) claims
BMJ 2014;349:g5702
But intolerance of uncertainty and error may be the most important reason that physicians engage in medical excess
“A toxic combination of vested interest and good intentions” Iona Heath BMJ 2013
McGauran et al. Trials 2010
Trials of Reboxetine Eyding D et al. BMJ 2010;341:bmj.c4737
Forest plot showing meta-analysis of published, unpublished, and all trials
Loder E, Lehman R. BMJ 2012
There is an “Alice in Wonderland” feel to these investigators’ efforts—acting on the public’s behalf, searching over hill and dale and among the paperwork of regulatory bodies and drug companies to put together pieces of data that should have been freely available in the first place.
Story of osteoporosis
Gray and Bolland BMJ 2015;351:h3170
Timeline of evidence from randomised trials of calcium with or without vitamin D with fracture as an outcome. (Large trials had >1000 participants.)
Gray and Bolland BMJ 2015;351:h3170
Gray and Bolland BMJ 2015;351:h3170
Gray and Bolland BMJ 2015;351:h3170
Kureshi et al, BMJ 2014;349:g5309 Kureshi et al BMJ 2014;349:g5309
Designer vaginas What is your problem with women, Ms. Godlee? This article's hysterical claims that a lack of testing and rigor in these procedures could result in permanent genital damage are nothing more than misogynist propaganda. Tell you what, the women of the world can keep their hands off your genitals if you keep your hands off theirs. When I'm faced with the choice, I'll pick the vagina attached to a woman who won't bow to the British Medical Journal's opinion. Best wishes, Laurence Shandy, feminist
Designer Vaginas Dear Laurence Shandy, Thank you for this. I have no strong opinions on the matter, except that I hope to get through life without surgery to my genitals, and think it appropriate for a medical journal to point out the potential dangers of surgery and the alternatives, at a time when reliable evidence is currently lacking. All best wishes, Dr Fiona Godlee , Editor in chief, BMJ
Designer vaginas Dear Dr. Godlee, I feel I owe you an apology. I’m sorry your genitals were dragged into this debate. Best wishes, Laurence Shandy, gentleman
What can we do to check medical excess? • Educate patients and the public about the nature of evidence and their role in healthcare decisions • Make time for shared decision making • Encourage conversations about deprescribing and end of life preferences • Focus on lifestyle change and quality of life • Campaign to raise awareness • Campaign for better more transparent and independent evidence for healthcare
Bmj.com/tamiflu
alltrials.net
http://evidencelive.org/manifesto/
Elizabeth Blackwell 1821 - 1910
A role for journals
“A subject that needs reform should be kept before the public until it demands reform.”
Hugh Clegg Editor BMJ 1947 to 1965
Thank you
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