Choosing Wisely in the UK: the Academy of Medical Royal Colleges' initiative to reduce the harms of too much medicine

Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study

INTRODUCTION

Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran.

METHODS

This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach.

RESULTS

Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants.

CONCLUSION

This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.

Developing Decision-Making Expertise in Professional Sports Staff: What We Can Learn from the Good Judgement Project

Success within performance sports is heavily dependent upon the quality of the decisions taken by educated and experienced staff. Multi-disciplinary teams (MDTs) typically collate voluminous data, and staff typically undergo extensive and rigorous technical and domain-specific training. Although sports professionals operate in sometimes volatile, uncertain, complex and ambiguous decision-making environments, a common assumption seems to be that education and experience will automatically lead to enhanced and effective decision-making capabilities. Accordingly, there are few formal curriculums, in coaching or sports science contexts, focussed on translating the extensive research on judgement and decision-making expertise to professional sports staff. This article aims to draw on key research findings to offer insights and practical recommendations to support staff working within professional performance contexts. Through this distillation, we hope to enhance understanding of the factors underpinning effective decision-making in dynamic, high-stakes professional sporting environments. Broadly, the conclusions of this research demonstrate that decision-making efficacy is enhanced through application of three specific strategies: (i) Design of more engaging professional cultures harnessing the power of collectives encouraging diverse opinions and perspectives, and fostering and promoting collaborative teamwork, (ii) education specifically targeting debiasing training, designed to counter the most common cognitive pitfalls and biases and, (iii) the implementation of evaluation strategies integrating rigorous testing and real-time feedback.

Physicians' views of patient-planetary health co-benefit prescribing: a mixed methods systematic review

Health professionals are increasingly called to become partners in planetary health. Using patient-planetary health (P-PH) co-benefit prescribing framing, we did a mixed methods systematic review to identify barriers and facilitators to adopting P-PH co-benefit prescribing by physicians and mapped these onto the Capability, Opportunity, Motivation, and Behaviour (COM-B) model and Theoretical Domains Framework (TDF). We searched electronic databases from inception until October, 2022, and did a content analysis of the included articles (n=12). Relevant categories were matched to items in the COM-B model and TDF. Nine barriers and eight facilitators were identified. Barriers included an absence of, or little, knowledge of how to change practice and time to implement change; facilitators included having policy statements and guidelines from respected associations. More diverse study designs that include health professionals, patients, and health-care system stakeholders are needed to ensure a more holistic understanding of the individual, system, and policy levers involved in implementing clinical work informed by planetary health.

Evaluation of the NHS England evidence-based interventions programme: a difference-in-difference analysis

BACKGROUND

The NHS England evidence-based interventions programme (EBI), launched in April 2019, is a novel nationally led initiative to encourage disinvestment in low value care.

METHOD

We sought to evaluate the effectiveness of this policy by using a difference-in-difference approach to compare changes in volume between January 2016 and February 2020 in a treatment group of low value procedures against a control group unaffected by the EBI programme during our period of analysis but subsequently identified as candidates for disinvestment.

RESULTS

We found only small differences between the treatment and control group after implementation, with reductions in volumes in the treatment group 0.10% (95% CI 0.09% to 0.11%) smaller than in the control group (equivalent to 16 low value procedures per month). During the month of implementation, reductions in volumes in the treatment group were 0.05% (95% CI 0.03% to 0.06%) smaller than in the control group (equivalent to 7 low value procedures). Using triple difference estimators, we found that reductions in volumes were 0.35% (95% CI 0.26% to 0.44%) larger in NHS hospitals than independent sector providers (equivalent to 47 low value procedures per month). We found no significant differences between clinical commissioning groups that did or did not volunteer to be part of a demonstrator community to trial EBI guidance, but found reductions in volume were 0.06% (95% CI 0.04% to 0.08%) larger in clinical commissioning groups that posted a deficit in the financial year 2018/19 before implementation (equivalent to 4 low value procedures per month).

CONCLUSIONS

Our analysis shows that the EBI programme did not accelerate disinvestment for procedures under its remit during our period of analysis. However, we find that financial and organisational factors may have had some influence on the degree of responsiveness to the EBI programme.

CHRDL1, NEFH, TAGLN and SYNM as novel diagnostic biomarkers of benign prostatic hyperplasia and prostate cancer

BACKGROUND

Prostate cancer (PCa) and benign prostatic hyperplasia (BPH) are common male diseases whose incidence rates gradually increase with age. They seriously affect men's physical health and quality of life. This study aimed to identify new biomarkers for the diagnosis of BPH and PCa.

METHODS

Two datasets, GSE28204 and GSE134051 (including human PCa and BPH), were downloaded from the GEO database. The batch effect was removed for merging, and then differential gene expression analysis was conducted to identify BPH and PCa cases. The diagnostic biomarkers of BPH and PCa were further screened using machine learning and bioinformatics. ROC curves were drawn to evaluate the diagnostic accuracy of the selected biomarkers. An online website and qPCR were used to preliminarily explore the expression levels of PCa biomarkers. The correlations between the expression of biomarkers and the tumor microenvironment, tumor mutation load and immunotherapy drugs were evaluated.

RESULTS

We identified fifteen genes (CHRDL1, DES, FLNC, GSTP1, MYL9, TGFB3, NEFH, TAGLN, SPARCL1, SYNM, TRPM8, HPN, PLA2G7, ENTPD5 and GPR160) as critical diagnostic biomarkers. After reviewing the literature on all selected biomarkers, we found few studies on the four genes CHRDL1, NEFH, TAGLN and SYNM in BPH or PCa. We defined these four genes as new potential diagnostic biomarkers (NPDBs) of BPH and PCa. All NPDBs were downregulated in PCa patients and PCa cell lines and upregulated in BPH patients and cell lines. When the immune landscape and mutation frequencies were analyzed, the results showed that the tumor microenvironment (TME), immune landscape, tumor mutation burden, and drug response were significantly correlated with NPDB expressions.

CONCLUSIONS

We found four new diagnostic markers of BPH and PCa, which may facilitate the early diagnosis, treatment, and immunotherapeutic responses assessment and may be of major value in guiding clinical practice.

Curing the pandemic of misinformation on COVID-19 mRNA vaccines through real evidence-based medicine - Part 1

Background

In response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), several new pharmaceutical agents have been administered to billions of people worldwide, including the young and healthy at little risk from the virus. Considerable leeway has been afforded in terms of the pre-clinical and clinical testing of these agents, despite an entirely novel mechanism of action and concerning biodistribution characteristics.

Aim

To gain a better understanding of the true benefits and potential harms of the messenger ribonucleic acid (mRNA) coronavirus disease (COVID) vaccines.

Methods

A narrative review of the evidence from randomised trials and real world data of the COVID mRNA products with special emphasis on BionTech/Pfizer vaccine.

Results

In the non-elderly population the “number needed to treat” to prevent a single death runs into the thousands. Re-analysis of randomised controlled trials using the messenger ribonucleic acid (mRNA) technology suggests a greater risk of serious adverse events from the vaccines than being hospitalised from COVID-19. Pharmacovigilance systems and real-world safety data, coupled with plausible mechanisms of harm, are deeply concerning, especially in relation to cardiovascular safety. Mirroring a potential signal from the Pfizer Phase 3 trial, a significant rise in cardiac arrest calls to ambulances in England was seen in 2021, with similar data emerging from Israel in the 16–39-year-old age group.

Conclusion

It cannot be said that the consent to receive these agents was fully informed, as is required ethically and legally. A pause and reappraisal of global vaccination policies for COVID-19 is long overdue.

Contribution

This article highlights the importance of addressing metabolic health to reduce chronic disease and that insulin resistance is also a major risk factor for poor outcomes from COVID-19.

Global and Local Trends Affecting the Experience of US and UK Healthcare Professionals during COVID-19: Twitter Text Analysis

Background: Healthcare professionals (HCPs) are on the frontline of fighting the COVID-19 pandemic. Recent reports have indicated that, in addition to facing an increased risk of being infected by the virus, HCPs face an increased risk of suffering from emotional difficulties associated with the pandemic. Therefore, understanding HCPs’ experiences and emotional displays during emergencies is a critical aspect of increasing the surge capacity of communities and nations. Methods: In this study, we analyzed posts published by HCPs on Twitter to infer the content of discourse and emotions of the HCPs in the United States (US) and United Kingdom (UK), before and during the COVID-19 pandemic. The tweets of 25,207 users were analyzed using natural language processing (NLP). Results: Our results indicate that HCPs in the two countries experienced common health, social, and political issues related to the pandemic, reflected in their discussion topics, sentiments, and emotional display. However, the experiences of HCPs in the two countries are also subject to local socio-political trends, as well as cultural norms regarding emotional display. Conclusions: Our results support the potential of utilizing Twitter discourse to monitor and predict public health responses in emergencies.

Evaluating the Co-design of an Age-Friendly, Rural, Multidisciplinary Primary Care Model: A Study Protocol

In the context of increased rates of frailty and chronic disease among older people, there is a need to develop age-friendly, integrated primary care models that place the older person at the centre of their care. However, there is little evidence about how age-friendly integrated care frameworks that are sensitive to the challenges of rural regions can be developed. This protocol paper outlines a study that will examine how the use of an age-friendly care framework (the Indigo 4Ms Framework) within a co-design process can facilitate the development of models of integrated care for rural older people within the Upper Hume region (Victoria, Australia). A co-design team will be assembled, which will include older people and individuals from local health, aged care, and community organisations. Process and outcome evaluation of the co-design activities will be undertaken to determine (1) the processes, activities and outputs that facilitate or hinder the co-design of a 4Ms integrated approach, and (2) how the use of the Indigo 4Ms Framework within a co-design process contributes to more integrated working practices. This protocol contributes to the development of a field of study examining how rural health and aged care services can become more age-friendly, with an emphasis on the role of co-design in developing integrated approaches to health care for older adults.

The need for "gentle medicine" in a post Covid-19 world

As it has historically been the case with many pandemics, the Covid-19 experience will induce many philosophers to reconsider the value of medical practice. This should be a good opportunity to critically scrutinize the way medical research and medical interventions are carried out. For much of its history, medicine has been very inefficient. But, even in its contemporary forms, a review of common protocols in medical research and medical interventions reveal many shortcomings, especially related to methodological flaws, and more importantly, conflicts of interests due to profit incentives. In the face of these problems, we propose a program of "gentle medicine". This term, originally formulated by philosopher Jacob Stegenga, describes a form of medicine in which physicians intervene less than they currently do. As part of this general program, we advance a series of reform recommendations that could be enacted both by medical staff in their everyday practice, but also by public health officials and policymakers.

Drugs for preventing postoperative nausea and vomiting in adults after general anesthesia: An abridged Cochrane network meta-analysis

OBJECTIVE

In this abridged version of the recently published Cochrane review on antiemetic drugs, we summarize its most important findings and discuss the challenges and the time needed to prepare what is now the largest Cochrane review with network meta-analysis in terms of the number of included studies and pages in its full printed form.

METHODS

We conducted a systematic review with network meta-analyses to compare and rank single antiemetic drugs and their combinations belonging to 5HT₃-, D₂-, NK₁-receptor antagonists, corticosteroids, antihistamines, and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anesthesia.

RESULTS

585 studies (97 516 participants) testing 44 single drugs and 51 drug combinations were included. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 studies, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared to placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single NK₁ receptor antagonists were as effective as other drug combinations. Of the 10 effective single drugs, certainty of evidence was high for aprepitant, ramosetron, granisetron, dexamethasone, and ondansetron, while moderate for fosaprepitant and droperidol. For serious adverse events (SAEs), any adverse event (AE), and drug-class specific side effects evidence for intervention effects was mostly not convincing.

CONCLUSIONS

There is high or moderate evidence for at least seven single drugs preventing postoperative vomiting. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.

Care Starts at Home: Emotional State and Appeals to Altruism may Reduce Demand for Overused Health Services in the UK

BACKGROUND

Overuse of unnecessary services, screening tests, and treatments is an ongoing problem for national health care systems. Overuse is at least partly driven by patient demand.

PURPOSE

This study examined whether altering patients' emotional state and appealing to patient altruism would reduce demand for three commonly overused UK health services.

METHODS

In an online experiment, 1,267 UK volunteers were randomized to anxiety, compassion, or neutral conditions before viewing three overuse vignettes. In each vignette, use of the health service was recommended against by the doctor and participants were further randomized to one of three altruism frames, emphasizing the impact of overuse on the self, the self and others locally, or the self and others nationally. Participants rated the likelihood that they would pursue the health service and, assuming that they did not, how long they would be willing-to-wait for it.

RESULTS

Altruism frame had a small effect on intentions to use the health service. Those in the local or national (vs. self) frame were 4.7 and 6.1 percentage points, respectively, less likely to ask for the service. Emotion induction had no direct effect on outcomes. However, self-reporting higher levels of anxiety or compassion post-induction was associated with a small, greater likelihood in intentions to ask for the health service or willingness-to-wait, respectively. No interactions between frame and emotion were observed.

CONCLUSIONS

As a low-cost initiative, emphasizing the benefits to the self and local or national communities could be embedded in appeals designed to appropriately reduce health care overuse in the UK.

Overdiagnosis and overtreatment: a sociological perspective on tackling a contemporary healthcare issue

Overdiagnosis and overtreatment are increasingly discussed as a significant problem in contemporary healthcare but are yet to receive any significant sociological attention, over and above that which is arguably transferable from the medicalisation literature. Overdiagnosis and overtreatment are often constructed as problems best addressed by educating patients and clinicians, and improving the relationships between them. The emergence of tools seeking to support decision-making and to facilitate patients' asking questions about whether interventions are really necessary supports this conceptualisation. This article questions whether significant traction on overdiagnosis and overtreatment is possible through these means alone, arguing that even when professionals and patients may wish to do less rather than more, the system within which care is delivered and received can make this challenging to achieve. Drawing on Scott's (Sociology, 2018, 52, 3) 'sociology of nothing', the article demonstrates that a sociological perspective on overdiagnosis and overtreatment recasts them as issues that must be understood as a consequence of the organisational, financial and cultural attributes of the system, not just individual interactions, and advances a research agenda for the area.

Cost impact of introducing a treatment escalation/limitation plan during patients' last hospital admission before death

OBJECTIVE

A recent study found that the use of a treatment escalation/limitation plan (TELP) was associated with a significant reduction in non-beneficial interventions (NBIs) and harms in patients admitted acutely who subsequently died. We quantify the economic benefit of the use of a TELP.

DESIGN

NBIs were micro-costed. Mean costs for patients with a TELP were compared to patients without a TELP using generalized linear model regression, and results were extrapolated to the Scottish population.

SETTING

Medical, surgical and intensive care units of district general hospital in Scotland, UK.

PARTICIPANTS

Two hundred and eighty-seven consecutive patients who died over 3 months in 2017. Of these, death was 'expected' in 245 (85.4%) using Gold Standards Framework criteria.

INTERVENTION

Treatment escalation/limitation plan.

MAIN OUTCOME MEASURE

Between-group difference in estimated mean cost of NBIs.

RESULTS

The group with a TELP (n = 152) had a mean reduction in hospital costs due to NBIs of GB £220.29 (US $;281.97) compared to those without a TELP (n = 132) (95% confidence intervals GB £323.31 (US $413.84) to GB £117.27 (US $150.11), P = <0.001). Assuming that a TELP could be put in place for all expected deaths in Scottish hospitals, the potential annual saving would be GB £2.4 million (US $3.1 million) from having a TELP in place for all 'expected' deaths in hospital.

CONCLUSIONS

The use of a TELP in an acute hospital setting may result in a reduction in costs attributable to NBIs.

Drugs for preventing postoperative nausea and vomiting in adults after general anaesthesia: an abridged Cochrane network meta-analysis

Postoperative nausea and vomiting is a common adverse effect of anaesthesia. Although dozens of different anti-emetics are available for clinical practice, there is currently no comparative ranking of efficacy and safety of these drugs to inform clinical practice. We performed a systematic review with network meta-analyses to compare, and rank in terms of efficacy and safety, single anti-emetic drugs and their combinations, including 5-hydroxytryptamine₃ , dopamine-2 and neurokinin-1 receptor antagonists; corticosteroids; antihistamines; and anticholinergics used to prevent postoperative nausea and vomiting in adults after general anaesthesia. We systematically searched for placebo-controlled and head-to-head randomised controlled trials up to November 2017 (updated in April 2020). We assessed how trustworthy the evidence was using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence In Network Meta-Analysis (CINeMA) approaches for vomiting within 24 h postoperatively, serious adverse events, any adverse event and drug class-specific side-effects. We included 585 trials (97,516 participants, 83% women) testing 44 single drugs and 51 drug combinations. The studies' overall risk of bias was assessed as low in only 27% of the studies. In 282 trials, 29 out of 36 drug combinations and 10 out of 28 single drugs lowered the risk of vomiting at least 20% compared with placebo. In the ranking of treatments, combinations of drugs were generally more effective than single drugs. Single neurokinin-1 receptor antagonists were as effective as other drug combinations. Out of the 10 effective single drugs, certainty of evidence was high for aprepitant, with risk ratio (95%CI) 0.26 (0.18-0.38); ramosetron, 0.44 (0.32-0.59); granisetron, 0.45 (0.38-0.54); dexamethasone, 0.51 (0.44-0.57); and ondansetron, 0.55 (0.51-0.60). It was moderate for fosaprepitant, 0.06 (0.02-0.21) and droperidol, 0.61 (0.54-0.69). Granisetron and amisulpride are likely to have little or no increase in any adverse event compared with placebo, while dimenhydrinate and scopolamine may increase the number of patients with any adverse event compared with placebo. So far, there is no convincing evidence that other single drugs effect the incidence of serious, or any, adverse events when compared with placebo. Among drug class specific side-effects, evidence for single drugs is mostly not convincing. There is convincing evidence regarding the prophylactic effect of at least seven single drugs for postoperative vomiting such that future studies investigating these drugs will probably not change the estimated beneficial effect. However, there is still considerable lack of evidence regarding safety aspects that does warrant investigation.

Minimum retesting intervals in practice: 10 years experience

Background

Minimum retesting intervals (MRI) are a popular demand management solution for the identification and reduction of over-utilized tests. In 2011 Association of Clinical Biochemistry and Laboratory Medicines (ACB) published evidence-based recommendations for the use of MRI.

Aim

The aim of the paper was to review the use of MRI over the period since the introduction of these recommendations in 2011 to 2020 and compare it to previous published data between 2000-2010.

Methods

A multi-source literature search was performed to identify studies that reported the use of a MRI in the management or identification of inappropriate testing between the years prior to (2000–2010) and after implementation (2011–2020) of these recommendations.

Results

31 studies were identified which met the acceptance criteria (2000–2010 n=4, 2011–2020 n=27). Between 2000 and 2010 4.6% of tests (203,104/4,425,311) were identified as failing a defined MRI which rose to 11.8% of tests (2,691,591/22,777,288) in the 2011–2020 period. For those studies between 2011 and 2020 reporting predicted savings (n=20), 14.3% of tests (1,079,972/750,580) were cancelled, representing a total saving of 2.9 M Euros or 2.77 Euro/test. The most popular rejected test was Haemoglobin A1c which accounted for nearly a quarter of the total number of rejected tests. 13 out 27 studies used the ACB recommendations.

Conclusions

MRI are now an established, safe and sustainable demand management tool for the identification and management of inappropriate testing. Evidence based consensus recommendations have supported the adoption of this demand management tool into practice across multiple healthcare settings globally and harmonizing laboratory practice.

Biomarkers That Differentiate Benign Prostatic Hyperplasia from Prostate Cancer: A Literature Review

Prediction of prostate cancer in primary care is typically based upon serum total prostate-specific antigen (tPSA) and digital rectal examination results. However, these tests lack sensitivity and specificity, leading to over-diagnosis of disease and unnecessary, invasive biopsies. Therefore, there is a clinical need for diagnostic tests that can differentiate between benign conditions and early-stage malignant disease in the prostate. In this review, we evaluate research papers published from 2009 to 2019 reporting biomarkers that identified or differentiated benign prostatic hyperplasia (BPH) from prostate cancer. Our review identifies hundreds of potential biomarkers in urine, serum, tissue, and semen proposed as useful targets for differentiating between prostate cancer and BPH patients. However, it is still not apparent which of these candidate biomarkers are most useful, and many will not progress beyond the discovery stage unless they are properly validated for clinical practice. We conclude that this validation will come through the use of multivariate panels which can assess the value of biomarker candidates in combination with clinical parameters as part of a risk prediction calculator. Implementation of such a model will help clinicians stratify patients with prostate cancer symptoms in primary care, with tangible benefits for both the patient and the health service.

Effectiveness of the clinical decision support tool ESR eGUIDE for teaching medical students the appropriate selection of imaging tests: randomized cross-over evaluation

OBJECTIVES

To evaluate ESR eGUIDE-the European Society of Radiology (ESR) e-Learning tool for appropriate use of diagnostic imaging modalities-for learning purposes in different clinical scenarios.

METHODS

This anonymized evaluation was performed after approval of ESR Education on Demand leadership. Forty clinical scenarios were developed in which at least one imaging modality was clinically most appropriate, and the scenarios were divided into sets 1 and 2. These sets were provided to medical students randomly assigned to group A or B to select the most appropriate imaging test for each scenario. Statistical comparisons were made within and across groups.

RESULTS

Overall, 40 medical students participated, and 31 medical students (78%) answered both sets. The number of correctly chosen imaging methods per set in these 31 paired samples was significantly higher when answered with versus without use of ESR eGUIDE (13.7 ± 2.6 questions vs. 12.1 ± 3.2, p = 0.012). Among the students in group A, who first answered set 1 without ESR eGUIDE (11.1 ± 3.2), there was significant improvement when set 2 was answered with ESR eGUIDE (14.3 ± 2.5, p = 0.013). The number of correct answers in group B did not drop when set 2 was answered without ESR eGUIDE (12.4 ± 2.6) after having answered set 1 first with ESR eGUIDE (13.0 ± 2.7, p = 0.66).

CONCLUSION

The clinical decision support tool ESR eGUIDE is suitable for training medical students in choosing the best radiological imaging modality in typical scenarios, and its use in teaching radiology can thus be recommended.

KEY POINTS

• ESR eGUIDE improved the number of appropriately selected imaging modalities among medical students. • This improvement was also seen in the group of students which first selected imaging tests without ESR eGUIDE. • In the student group which used ESR eGUIDE first, appropriate selection remained stable even without the teaching tool.

Realistic Medicine: Changing culture and practice in the delivery of health and social care

OBJECTIVE

Current models of health and social care services are stretched and do not always suit patients, their carers or the aspirations of the workforce. Realistic Medicine aims to improve patient care by ensuring that people receive appropriate, beneficial, evidence-based care aligned with their personal preferences. This paper builds on a keynote address delivered at ICCH 2018.

METHODS

We explore the six core principles of Realistic Medicine: (i) building a personalised approach to patient care; (ii) changing style to shared decision-making; (iii) reducing harm and waste; (iv) tackling unwarranted variation in practice and outcomes; (v) managing risk better; (vi) becoming improvers and innovators in healthcare.

RESULTS

Realistic Medicine is being embedded across Scotland, championed by local and national clinical leaders. There is particular focus on engaging patients around shared-decision making and improving value in healthcare.

CONCLUSION

Realistic Medicine is the first example of these principles being articulated clearly and collectively as the essential components of a health and care system's national improvement strategy. It reflects the care that most professional staff wish to provide.

PRACTICE IMPLICATIONS

To deliver Realistic Medicine, all health and social care professionals must be empowered to work together in teams, networks and in partnership with people.

The French Society of Internal Medicine's Top-5 List of Recommendations: a National Web-Based Survey

BACKGROUND

The international project "Choosing Wisely" aims to target unnecessary and potentially harmful examinations and treatments.

OBJECTIVE

To define the French Internal Medicine Top-5 list.

DESIGN

Based on a review of existing Top-5 lists and personal experience, a working group of the French National Society of Internal Medicine selected 27 diagnostic and therapeutic procedures. They were submitted through a national web-based survey to French internists who rated from 1 to 5 the perceived frequency, uselessness, and risk of each procedure. A composite score was calculated as the unweighted addition of the three scores.

PARTICIPANTS

Four hundred thirty internists answered the web-based survey (14% of all French internists including residents). All the French regions and status of the profession were represented.

KEY RESULTS

For the 27 submitted procedures, the mean score (± SD) was 3.25 (± 0.48) for frequency, 3.10 (± 0.43) for uselessness, and 2.63 (± 0.84) for risk. The Top-5 list obtained with the composite score was as follows: 1. Do not prescribe long-term treatment with proton pump inhibitors without regular reevaluation of the indication 2. Do not administer preventive treatments (e.g., for dyslipidemia, hypertension…) in elderly people with dementia when potential risks outweigh the benefits 3. Do not administer hypnotic medications as first-line treatment for insomnia 4. Do not treat with an anticoagulant for more than 3 months a patient with a first venous thromboembolism occurring in the setting of a major transient risk factor 5. Do not screen for Lyme disease without an exposure history or related clinical examination findings We found that the composite score was strongly correlated to the risk score (r_s = 0.88, p < 10^-5) and not to the frequency (r_s = 0.06, p = 0.75) or uselessness score (r_s = 0.17, p = 0.38).

CONCLUSIONS

This Top-5 list provides an opportunity to discuss appropriate use of health care practices in internal medicine.

Understanding the diagnosis of pre-diabetes in patients aged over 85 in English primary care: a qualitative study

Background

The benefit of a “diagnosis” of pre-diabetes in very elderly patients is debated. How clinicians manage pre-diabetic blood results in these patients is unknown. This study aims to understand how clinicians are “diagnosing” older patients with pre-diabetic blood parameters.

Methods

Semi-structured interviews and focus groups with health care staff (24 total participants) were conducted in the north of England. Interviews and focus groups were recorded, transcribed and analysed thematically. A grounded theory approach was taken with the theory of candidacy being used as a sensitising concept through which questions were framed and results interpreted.

Results

There is a complex system of competing pressures that influence a clinician in deciding whether, and in what way, to inform a very elderly patient that they have pre-diabetes. The majority of clinicians adjust their management of pre-diabetes to the age and perceived risk/benefit for the patient. Whilst some clinicians choose not to inform certain patients of their blood results, many clinicians maintain, what could be seen as a somewhat paradoxical approach of labeling all older patients with pre-diabetes but downplaying the significance to the patient. The policy, organisational context, workload and professional constraints under which clinicians work, play a significant role in shaping how they deal with pre-diabetic blood results in the very elderly.

Conclusion

There has been recent acknowledgement of how policy and organisational context frames decision-making, but there is a lack of evidence on how this influences uncertainty and dilemmas in decision-making in practice. These findings add further weight for the argument that treatment burden should be included in clinical guidelines.

Restrictive strategy versus usual care for cholecystectomy in patients with gallstones and abdominal pain (SECURE): a multicentre, randomised, parallel-arm, non-inferiority trial

BACKGROUND

International guidelines advise laparoscopic cholecystectomy to treat symptomatic, uncomplicated gallstones. Usual care regarding cholecystectomy is associated with practice variation and persistent post-cholecystectomy pain in 10-41% of patients. We aimed to compare the non-inferiority of a restrictive strategy with stepwise selection with usual care to assess (in)efficient use of cholecystectomy.

METHODS

We did a multicentre, randomised, parallel-arm, non-inferiority study in 24 academic and non-academic hospitals in the Netherlands. We enrolled patients aged 18-95 years with abdominal pain and ultrasound-proven gallstones or sludge. Patients were randomly assigned (1:1) to either usual care in which selection for cholecystectomy was left to the discretion of the surgeon, or a restrictive strategy with stepwise selection for cholecystectomy. For the restrictive strategy, cholecystectomy was advised for patients who fulfilled all five pre-specified criteria of the triage instrument: 1) severe pain attacks, 2) pain lasting 15-30 min or longer, 3) pain located in epigastrium or right upper quadrant, 4) pain radiating to the back, and 5) a positive pain response to simple analgesics. Randomisation was done with an online program, implemented into a web-based application using blocks of variable sizes, and stratified for centre (academic versus non-academic and a high vs low number of patients), sex, and body-mass index. Physicians and patients were masked for study-arm allocation until after completion of the triage instrument. The primary, non-inferiority, patient-reported endpoint was the proportion of patients who were pain-free at 12 months' follow-up, analysed by intention to treat and per protocol. A 5% non-inferiority margin was chosen, based on the estimated clinically relevant difference. Safety analyses were also done in the intention-to treat population. This trial is registered at the Netherlands National Trial Register, number NTR4022.

FINDINGS

Between Feb 5, 2014, and April 25, 2017, we included 1067 patients for analysis: 537 assigned to usual care and 530 to the restrictive strategy. At 12 months' follow-up 298 patients (56%; 95% CI, 52·0-60·4) were pain-free in the restrictive strategy group, compared with 321 patients (60%, 55·6-63·8) in usual care. Non-inferiority was not shown (difference 3·6%; one-sided 95% lower CI -8·6%; p_{non-inferiority}=0·316). According to a secondary endpoint analysis, the restrictive strategy resulted in significantly fewer cholecystectomies than usual care (358 [68%] of 529 vs 404 [75%] of 536; p=0·01). There were no between-group differences in trial-related gallstone complications (40 patients [8%] of 529 in usual care vs 38 [7%] of 536 in restrictive strategy; p=0·16) and surgical complications (74 [21%] of 358 vs 88 [22%] of 404, p=0·77), or in non-trial-related serious adverse events (27 [5%] of 529 vs 29 [5%] of 526).

INTERPRETATION

Suboptimal pain reduction in patients with gallstones and abdominal pain was noted with both usual care and following a restrictive strategy for selection for cholecystectomy. However, the restrictive strategy was associated with fewer cholecystectomies. The findings should encourage physicians involved in the care of patients with gallstones to rethink cholecystectomy, and to be more careful in advising a surgical approach in patients with gallstones and abdominal symptoms.

FUNDING

The Netherlands Organization for Health Research and Development, and CZ healthcare insurance.

Optimising laboratory monitoring of chronic conditions in primary care: a quality improvement framework

Monitoring of chronic conditions accounts for a significant proportion of blood testing in UK primary care; not all of this is based on evidence or guidelines. National benchmarking shows significant variation in testing rates for common blood tests. This project set out to standardise the blood tests used for monitoring of chronic conditions in primary care across North Devon, and to measure and reduce the harms of unwarranted testing. Chronic disease test groups were developed in line with current guidelines and implemented using one-click electronic test ordering systems. The main difference from previous general practitioner practice algorithms was removing the requirement for full blood count and liver function test monitoring for many conditions. Baseline harms of testing were measured and included significant costs, workload and patient anxiety. By defining the scale of the problem, we were able to leverage change across several cycles of quality improvement, using a pathology optimisation forum for peer-led improvement, and developing a framework focusing on what matters to patients. Overall primary care testing rates in North Devon fell by 14% for full blood count testing and 22% for liver function tests, but without a reduction in the number of tests showing possible significant pathology. We estimate that this has reduced testing costs by £200 000 across a population of around 180 000 people and has reduced downstream referral costs by a similar amount. Introduction of simple chronic disease test groups into primary care electronic ordering systems, when used alongside engagement with clinicians, leads to both quality improvement and reduction in system costs.

Laboratory tests commonly used in complementary and alternative medicine: a review of the evidence

It is increasingly easy for the general public to access a wide range of laboratory tests. Tests can be ordered online with little or no input from a health professional. The complementary and alternative medicine (CAM) community promote and sell a wide range of tests, many of which are of dubious clinical significance. Many have little or no clinical utility and have been widely discredited, whilst others are established tests that are used for unvalidated purposes. They range from the highly complex, employing state of the art technology, e.g. heavy metal analysis using inductively coupled plasma-mass spectrometry, to the rudimentary, e.g. live blood cell analysis. Results of 'CAM tests' are often accompanied by extensive clinical interpretations which may recommend, or be used to justify, unnecessary or harmful treatments. There are now a small number of laboratories across the globe that specialize in CAM testing. Some CAM laboratories operate completely outside of any accreditation programme whilst others are fully accredited to the standard of established clinical laboratories. In this review, we explore CAM testing in the United States, the United Kingdom and Australia with a focus on the common tests on offer, how they are reported, the evidence base for their clinical application and the regulations governing their use. We will also review proposed changed to in-vitro diagnostic device regulations and how these might impact on CAM testing.

Pre-operative optimisation of the surgical patient with diagnosed and undiagnosed diabetes: a practical review

Peri-operative hyperglycaemia, whether the cause is known diabetes, undiagnosed diabetes or stress hyperglycaemia, is a risk factor for harm, increased length of stay and death. There is increasing evidence that peri-operative hyperglycaemia is a modifiable risk factor, and many of the interventions required to improve the outcome of surgery must be instituted before the actual surgical admission. These interventions depend on communication and collaboration within the multidisciplinary team along each stage of the patient journey to ensure that integration of care occurs across the whole of the patient-centred care pathway.

Implementing Prudent Healthcare in the NHS in Wales; what are the barriers and enablers for clinicians?

RATIONALE

Prudent Healthcare is a strategy adopted by the Welsh Government in response to the challenge of improving health care during times of austerity and when needs and demand are rising. Four principles underlie Prudent Healthcare: to achieve health and wellbeing through co production; care for those with the greatest health needs first; do only what is needed; and reduce inappropriate variation. For Prudent Healthcare to be implemented in Wales, it is necessary for health professionals to adopt these principles in practice.

OBJECTIVE

This paper reports a qualitative evaluation of clinicians' awareness, experiences, and views about Prudent Healthcare, identifying barriers and enablers to implementation from the clinician's perspective.

METHODS

Semi-structured interviews (n = 28) and five focus groups (with 23 participants) were undertaken with a diverse range of health professionals working in primary and secondary care. Analysis was underpinned by the COM-B model which provides a framework to understand behaviour change in context using three domains, Capability, Opportunity, and Motivation.

RESULTS

Clinicians reported the importance and challenges of accessing and sharing information and evidence to inform practice (Capability). Reduced staffing levels and service availability were highlighted as possible barriers to Prudent Healthcare implementation while multidisciplinary working and reorganization of staff roles and services were considered enablers (Opportunity). Finally, although the principles of Prudent Healthcare were broadly welcomed (Motivation), a lack of awareness of the initiative and the management of patient expectations presented barriers.

CONCLUSION

While there was a positive response and widespread support for the principles of Prudent Healthcare by clinicians, increasing awareness of the initiative and improvement to systems to enable information sharing and the monitoring of patient outcomes could improve the consistency of implementation.

Prophylactic sivelestat for esophagectomy and in-hospital mortality: a propensity score-matched analysis of claims database

PURPOSE

Transthoracic esophagectomy is an invasive surgery, and the excessive surgical stress produces inflammatory cytokines, which provoke acute respiratory distress syndrome (ARDS). Sivelestat sodium hydrate-a selective neutrophil elastase inhibitor-is used to treat or prevent ARDS in patients undergoing esophagectomy, although clear evidence is lacking. We investigated the benefits and risk of prophylactic sivelestat.

METHODS

This retrospective study used an administrative claims database in Japan. Adult patients who underwent transthoracic esophagectomy from 2010 to 2016 were identified and divided into a prophylactic sivelestat use group and a non-prophylactic use group that included both non-users and therapeutic users. The primary outcome was all-cause in-hospital mortality, and a secondary outcome included the proportion of ARDS. We used 1:1 propensity score matching. For sensitivity analyses, we conducted a 1:2 propensity score matching analysis and several analyses with various patient inclusion criteria.

RESULTS

Of the 3391 patients with esophagectomy, 621 received prophylactic sivelestat. On unadjusted analysis, the sivelestat group had a higher proportion of in-hospital mortality (5.3% vs. 2.9%) compared with the control group. We created a matched cohort of 615 pairs, whose baseline characteristics were well balanced. On adjusted analysis using propensity score matching, prophylactic sivelestat administration was not associated with decreased in-hospital mortality [adjusted odds ratio (aOR) 1.65; 95% confidence interval (CI) 0.95-2.88], ARDS rate (aOR 1.25; 95% CI 0.49-3.17). The findings were also consistent with other sensitivity analyses.

CONCLUSION

Because mortality and postoperative complications were similar, our findings do not support prophylactic sivelestat administration for patients undergoing esophagectomy.

Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

OBJECTIVES

To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.

DESIGN

A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance.

SETTING

Medical, surgical and intensive care units of a district general hospital.

OUTCOMES

The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method.

RESULTS

289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).

CONCLUSIONS

The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.

Optimizing medical care for geriatric patients in Austria: defining a top five list of "Choosing Wisely" recommendations using the Delphi technique

Purpose

Inappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients.

Methods

From an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds.

Results

The final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria.

Conclusions

The selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.

A healthy lifestyle attenuates the effect of polypharmacy on total and cardiovascular mortality: a national prospective cohort study

This work examines whether the increased all-cause and cardiovascular disease (CVD) mortality associated with polypharmacy could be offset by a healthy lifestyle. We included a prospective cohort of 3,925 individuals representative of the Spanish population aged ≥60 years, who were recruited in 2000–2001 and followed up through 2014. Polypharmacy was defined as treatment with ≥5 medications. The following lifestyle behaviors were considered healthy: not smoking, eating a healthy diet, being physically active, moderate alcohol consumption, low sitting time, and adequate sleep duration. Individuals were classified into three lifestyle categories s: unfavorable (0–2), intermediate (3–4) favorable (5–6). Over a median 13.8-y follow-up, 1,822 all-cause and 675 CVD deaths occurred. Among individuals with polypharmacy, intermediate and favorable lifestyles were associated with an all-cause mortality reduction (95% confidence interval [CI]) of 47% (34–58%) and 54% (37–66%), respectively; 37% (9–56%) and 60% (33–76%) for CVD death, respectively. The theoretical adjusted hazard ratio (95%CI) associated with replacing 1 medication with 1 healthy lifestyle behavior was 0.73 (0.66–0.81) for all-cause death and 0.69 (0.59–0.82) for CVD death. The theoretical adjusted hazard ratio (95%CI) for all-cause and CVD mortality associated with simply reducing 1 medication was 0.88 (0.83–0.94) and 0.83 (0.76–0.91), respectively. Hence, adherence to a healthy lifestyle behavior can reduce mortality risk associated with polypharmacy in older adults.

Should UK based Physiotherapists Choose Wisely?

In 2012 the Choose Wisely campaign was launched in the United States in order to address concerns regarding medicalisation, over diagnosis and medical consumerism. The campaign has now spread internationally and includes a number of countries including Canada, Australia, New Zealand and Germany. The primary aim of the campaign is to facilitate healthcare professionals and patients to question the overall utility of medical interventions. Professionals through their professional organisations identify at least five commonly used interventions or tests, within their areas of speciality, which they feel provided no or little benefit to patients. This paper provides the background to the Choose Wisely campaign. The paper reviews the concepts of medicalisation, over diagnosis and medical consumerism, before considering the utility of the campaign in the UK alongside other forms of governance such as NICE. The paper goes on to consider distributive justice as the principal ethical issue related to the campaign. The paper concludes by asking if UK based Physiotherapists should Choose Wisely.

Pharmacists Becoming Physicians: For Better or Worse?

Physicians and pharmacists nowadays are often described as adversaries rather than members of the same team. Some pharmacists apply to medical school later in their careers, and experience obstacles during the transition process. This article details interviews with two physician–pharmacists, who each have a past pharmacist license and current physician license. The respondents described the limitations of pharmacists’ scope of practice as their main reasons to pursue a medical career. However, the respondents enjoy applying their pharmacy knowledge and experience to improve their medical practice. They do not feel pharmacy seniors and medical recruiters are supportive towards their chase for medical careers. The respondents noted the importance of peer-reviewed articles to promote pharmacist involvement in patient care and collaboration between physicians and pharmacists. Conflicts between physicians and pharmacists tend to happen because of their different focuses on patient care. The respondents do not see themselves having an edge over other medical school applicants, and noted that recruiters could negatively view their pharmacy experience. The respondents believe that physician–pharmacists are catalysts to foster collaboration between physicians and pharmacists, because they clearly understand the role of each profession. Nevertheless, the respondents feel that physicians and pharmacists are generally lukewarm towards pharmacists transitioning into physicians.

Lower extremity osteoarthritis: optimising musculoskeletal health is a growing global concern: a narrative review

The burden of non-communicable diseases, such as osteoarthritis (OA), continues to increase for individuals and society. Regrettably, in many instances, healthcare professionals fail to manage OA optimally. There is growing disparity between the strength of evidence supporting interventions for OA and the frequency of their use in practice. Physical activity and exercise, weight management and education are key management components supported by evidence yet lack appropriate implementation. Furthermore, a recognition that treatment earlier in the disease process may halt progression or reverse structural changes has not been translated into clinical practice. We have largely failed to put pathways and procedures in place that promote a proactive approach to facilitate better outcomes in OA. This paper aims to highlight areas of evidence-based practical management that could improve patient outcomes if used more effectively.

'Choosing Wisely' culture among Brazilian cardiologists

Objective

(i) To describe how aligned the 'Choosing Wisely' concept is with the medical culture among Brazilian cardiologists and (ii) to identify predictors for physicians' preference for avoiding wasteful care.

Design

Cross-sectional study.

Setting

Brazilian Society of Cardiology.

Participants

Cardiologists who agree to fill a web questionary.

Intervention

A task force of 12 Brazilian cardiologists prepared a list of 13 'do not do' recommendations, which were made available on the Brazilian Society of Cardiology website for affiliates to assign a supported score of 1 to 10 to each recommendation.

Main Outcome Measurement

Score average for supporting recommendations.

Results

Of 14 579 Brazilian cardiologists, 621 (4.3%) answered the questionnaire. The top recommendation was 'do not perform routine percutaneous coronary intervention in asymptomatic individuals' (mean score = 8.0 ± 2.9) while the one with the lowest support was 'do not use an intra-aortic balloon pump in infarction with cardiogenic shock' (5.8 ± 3.2). None of the 13 recommendations presented a mean grade >9 (strong support); 7 recommendations averaged 7-8 (moderate support) followed by 6 recommendations with an average of 5-7 (modest support). Multivariate analysis independently identified predictors of the score attributed to the top recommendation; being an interventionist and time since graduation were both negatively associated with support.

Conclusions

(i) The support of Brazilian cardiologists for the 'Choosing Wisely' concept is modest to moderate, and (ii) older generations and enthusiasm towards the procedure one performs may be factors against the 'Choosing Wisely' philosophy.

Improving public understanding of 'overdiagnosis' in England: a population survey assessing familiarity with possible terms for labelling the concept and perceptions of appropriate terminology

OBJECTIVES

Communicating the concept of 'overdiagnosis' to lay individuals is challenging, partly because the term itself is confusing. This study tested whether alternative descriptive labels may be more appropriate.

DESIGN

Questionnaire preceded by a description of overdiagnosis.

SETTING

Home-based, computer-assisted face-to-face survey.

PARTICIPANTS

2111 adults aged 18-70 years in England recruited using random location sampling by a survey company. Data from 1888 participants were analysed after exclusions due to missing data.

INTERVENTIONS

Participants were given one of two pieces of text describing overdiagnosis, allocated at random, adapted from National Health Service breast and prostate cancer screening leaflets.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcomes were which of several available terms (eg, 'overdetection') participants had previously encountered and which they endorsed as applicable labels for the concept described. Demographics and previous exposure to screening information were also measured. Main outcomes were summarised with descriptive statistics. Predictors of previously encountering at least one term, or endorsing at least one as making sense, were assessed using binary logistic regression.

RESULTS

58.0% of participants had not encountered any suggested term; 44.0% did not endorse any as applicable labels. No term was notably familiar; the proportion of participants who had previously encountered each term ranged from 15.9% to 28.3%. Each term was only endorsed as applicable by a minority (range: 27.6% to 40.4%). Notable predictors of familiarity included education, age and ethnicity; participants were less likely to have encountered terms if they were older, not white British or had less education. Findings were similar for both pieces of information.

CONCLUSIONS

Familiarity with suggested terms for overdiagnosis and levels of endorsement were low, and no clear alternative labels for the concept were identified, suggesting that changing terminology alone would do little to improve understanding, particularly for some population groups. Explicit descriptions may be more effective.

Methods for the evaluation of biomarkers in patients with kidney and liver diseases: multicentre research programme including ELUCIDATE RCT

Background

Protein biomarkers with associations with the activity and outcomes of diseases are being identified by modern proteomic technologies. They may be simple, accessible, cheap and safe tests that can inform diagnosis, prognosis, treatment selection, monitoring of disease activity and therapy and may substitute for complex, invasive and expensive tests. However, their potential is not yet being realised.

Design and methods

The study consisted of three workstreams to create a framework for research: workstream 1, methodology – to define current practice and explore methodology innovations for biomarkers for monitoring disease; workstream 2, clinical translation – to create a framework of research practice, high-quality samples and related clinical data to evaluate the validity and clinical utility of protein biomarkers; and workstream 3, the ELF to Uncover Cirrhosis as an Indication for Diagnosis and Action for Treatable Event (ELUCIDATE) randomised controlled trial (RCT) – an exemplar RCT of an established test, the ADVIA Centaur® Enhanced Liver Fibrosis (ELF) test (Siemens Healthcare Diagnostics Ltd, Camberley, UK) [consisting of a panel of three markers – (1) serum hyaluronic acid, (2) amino-terminal propeptide of type III procollagen and (3) tissue inhibitor of metalloproteinase 1], for liver cirrhosis to determine its impact on diagnostic timing and the management of cirrhosis and the process of care and improving outcomes.

Results

The methodology workstream evaluated the quality of recommendations for using prostate-specific antigen to monitor patients, systematically reviewed RCTs of monitoring strategies and reviewed the monitoring biomarker literature and how monitoring can have an impact on outcomes. Simulation studies were conducted to evaluate monitoring and improve the merits of health care. The monitoring biomarker literature is modest and robust conclusions are infrequent. We recommend improvements in research practice. Patients strongly endorsed the need for robust and conclusive research in this area. The clinical translation workstream focused on analytical and clinical validity. Cohorts were established for renal cell carcinoma (RCC) and renal transplantation (RT), with samples and patient data from multiple centres, as a rapid-access resource to evaluate the validity of biomarkers. Candidate biomarkers for RCC and RT were identified from the literature and their quality was evaluated and selected biomarkers were prioritised. The duration of follow-up was a limitation but biomarkers were identified that may be taken forward for clinical utility. In the third workstream, the ELUCIDATE trial registered 1303 patients and randomised 878 patients out of a target of 1000. The trial started late and recruited slowly initially but ultimately recruited with good statistical power to answer the key questions. ELF monitoring altered the patient process of care and may show benefits from the early introduction of interventions with further follow-up. The ELUCIDATE trial was an ‘exemplar’ trial that has demonstrated the challenges of evaluating biomarker strategies in ‘end-to-end’ RCTs and will inform future study designs.

Conclusions

The limitations in the programme were principally that, during the collection and curation of the cohorts of patients with RCC and RT, the pace of discovery of new biomarkers in commercial and non-commercial research was slower than anticipated and so conclusive evaluations using the cohorts are few; however, access to the cohorts will be sustained for future new biomarkers. The ELUCIDATE trial was slow to start and recruit to, with a late surge of recruitment, and so final conclusions about the impact of the ELF test on long-term outcomes await further follow-up. The findings from the three workstreams were used to synthesise a strategy and framework for future biomarker evaluations incorporating innovations in study design, health economics and health informatics.

Trial registration

Current Controlled Trials ISRCTN74815110, UKCRN ID 9954 and UKCRN ID 11930.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 3. See the NIHR Journals Library website for further project information.

An echo to Choosing Wisely® in Switzerland

Background

Inspired by the US Choosing Wisely^®, in 2016 the Swiss Society of General Internal Medicine released a list of five treatments or diagnostic tests used in the hospital and considered unnecessary based on not improving patient care and adding to health care costs. These "Smarter Medicine" recommendations were implemented in the Department of Internal Medicine, Uster Hospital, in August 2016. They were supported by lectures and weekly email communications. We analyzed the number of blood draws before and after implementation of the recommendation aimed at reducing blood tests.

Methods

This retrospective analysis was conducted in the Department of Internal Medicine, Uster Hospital, Canton of Zurich, Switzerland. Patients hospitalized in the 3 months before and after implementation were analyzed.

Results

A total of 2023 hospitalizations were analyzed. There was a significant decrease in the number of blood draws after introduction of the recommendation: before implementation, the median number of blood draws per patient was 4 (interquartile range [IQR], 2-7); after implementation, the median was 4 (IQR, 2-6; P = 0.002). Indeed, since 46% of the patients in the first group had more than four blood tests, this ratio decreased to 39% after implementation.

Discussion

Inappropriate blood draws may lead to anemia, patient discomfort and false-positive results. The simple and low-cost interventions used to implement "Smarter Medicine" have changed physician behavior by reducing the number of blood orders. These results are promising. Whether such recommendations will impact patient and clinical outcomes remains unknown; hence, further studies are needed to clarify this issue.

Futility and appropriateness: challenging words, important concepts

The provision of healthcare is being challenged by a 'perfect storm' of forces including an increasing population with multiple comorbidities, high expectations and resource limitations, and in the background, the pre-eminence of the 'curative medical model'. Non-beneficial (futile) treatments are wasteful and costly. They have a negative impact on quality of life especially in the last year of life. Among professionals, frequent encounters with futility cause moral distress and demoralisation. The factors that drive non-beneficial treatments include personal biases, patient-related pressures and institutional imperatives. Breaking loose from the perceived necessity to deliver non-beneficial treatment is a major challenge. Curative intent should give way to appropriateness such that curative and palliative interventions are valued equally. Goals of treatment should be shaped by illness trajectory, the risk of harms as well as potential benefits and patient preferences. This strategy should be reflected in professional training and the design of acute services.

Diagnosis and treatment: Are psychiatrists choosing wisely?

The UK's Choosing Wisely campaign aims to tackle the pressing issue of overuse in healthcare (i.e. overdiagnosis and overtreatment) through improving awareness and promoting shared decisionmaking. This campaign involves medical societies developing lists of interventions that are of questionable value and so require a genuine discussion between doctors and patients about their use. This article is about the problem of overuse and the launch of the Royal College of Psychiatrists' Choosing Wisely campaign. It provides a critical review of why this might occur and whether Choosing Wisely is likely to be successful.

Learning Objectives

• Understand the aims of the Choosing Wisely programme

• Define overdiagnosis and overtreatment

• Develop a critical perspective on potential areas of overuse in your clinical practice

How is defensive medicine understood and experienced in a primary care setting? A qualitative focus group study among Danish general practitioners

OBJECTIVES

Recent years have witnessed a progressive increase in defensive medicine (DM) in several Western welfare countries. In Danish primary and secondary care, documentation on the extent of DM is lacking. Before investigating the extent of DM, we wanted to explore how the phenomenon is understood and experienced in the context of general practice in Denmark. The objective of the study was to describe the phenomenon of DM as understood and experienced by Danish general practitioners (GPs).

DESIGN

A qualitative methodology was employed and data were generated through six focus group interviews with three to eight GPs per group (n=28) recruited from the Region of Southern Denmark. Data were analysed using a thematic content analysis inspired by a hermeneutic-phenomenological focus on understanding and meaning.

RESULTS

DM is understood as unnecessary and meaningless medical actions, carried out mainly because of external demands that run counter to the GP's professionalism. Several sources of pressure to act defensively were identified by the GPs: the system's pressure to meet external regulations, demands from consumerist patients and a culture among GPs and peers of infallibility and zero-risk tolerance.

CONCLUSIONS

GPs understand DM as unnecessary and meaningless actions driven by external demands instead of a focus on the patient's problem. GPs consider defensive actions to be carried out as a result of succumbing to various sources of pressure deriving from the system, the patients, the GPs themselves and peers.

[The Choosing Wisely Initiative (CWI): Background, aims and problems of a professional campaign against oversupply]

The Choosing Wisely Initiative (CWI) started in 2012 follows a proposal by Howard Brody (2010). Using CWI, the US ABIM Foundation continued its work to strengthen medical professionalism. The text describes CWI's development, aims, mission, and dissemination. It discusses some of its limits and problems. An appendix tabulates similarities and differences between CWI and a (2016) subsequent initiative from the German Society of Internal Medicine (DGIM: Klug Entscheiden Empfehlungen/decide wisely recommendations).

What do tests do for doctors? A qualitative study of blood testing in UK primary care

BACKGROUND

Rates of blood testing are rising with significant geographical variability. Most research into diagnostic testing focuses on the role of tests in diagnostic decision-making.

OBJECTIVE

The aim of this study was to explore the non-medical motives for blood testing by considering what tests do for doctors, through qualitative interviews with general practitioners (GPs).

METHODS

We undertook 23 in-depth semi-structured interviews with UK GPs. Reasons for performing recent inflammatory marker blood tests were explored by reviewing GPs pathology inboxes to ground discussions in real-life clinical practice. Interviews were transcribed verbatim and analysed using a grounded theory approach.

RESULTS

Blood tests offer doctors a tool to manage uncertainty; within a context of increased litigation, risk aversion and reduced continuity of care. Tests can also be offered as a 'gift' for patients, a way to be seen to be 'doing something'; in the social context of time pressures and perceived patient pressures. There was a tension however. On the one hand, doctors talked about using tests for reassurance and as a 'gift' offering 'truth'. Yet paradoxically, they also discussed the challenges of uncertainty and anxiety from inconclusive test results.

CONCLUSION

Our study emphasises that defining 'unnecessary' blood testing may not be as simple as determining medical criteria for testing; psychosocial reasons may be equally valid and interlinked. Further research is needed to help GPs manage uncertainty within the context of a risk averse society, and to explore the congruence and dissonance between doctors' and patients' perceptions of testing.