Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2308 (Published 12 May 2015) Cite this as: BMJ 2015;350:h2308
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At long last I finally feel that the over prescribing of medication by doctors is being recognized as an issue worthy of further analysis. However my main area of concern is the prescribing of completely unnecessary medications when patients are either discharged or who go on leave from an in-patient setting. The amount of waste in this particular area is alarming to say the least. I have both professional and personal experience of this largess and would hope that the urge to always prescribe seven days supply of discharge medication is challenged.
Patients frequently have medications at home or have repeat prescriptions waiting to be picked up. Ward doctors, particularly on discharge, always seem to assume that patients will ALWAYS need seven days supply irrespective of their individual circumstances. I have often been told that this is a 'protocol' and 'has to be done'.
I believe that hospital ward budgets suffer greatly in this regard as well as the taxpayer of course. Only this year when I picked up my late father from a hospital admission was he given seven days supply of medication.This was in spite of my best efforts to inform ward staff that he had more than enough medication at home and had regular repeat prescriptions from his GP.
I refused to take the medications with me and suggested they could be used to supplement ward stock. Naturally I would of course have taken new medication from the ward had his treatment regime been altered.
Lastly, there have been times when certain patients (especially in my clinical area) have left hospital leaving their discharge medications behind on the ward. Can these unused medications be returned ? Absolutely not, they end up being incinerated.
Competing interests: No competing interests
Patient-centered health care is one of the most effective solutions available to address the issues raised by Choosing Wisely. Patient-engagement and patient-involvement of 'expert-patients' with their own health care decisions and with decisions embedded in general policies and protocols within health care systems (systemic approach) will go a long way to make health systems effective and efficient. Choosing Wisely will work as long as those choosing wisely happen to be the patients themselves.
At the background of over prescribing, the threat of anti-microbial resistance (AMR) is raising its profile. The call for a £2 billion AMR fund by Prof. Sally Davies is a complementary issue with Choosing Wisely.
Competing interests: No competing interests
Factors related to “Choosing wisely”:
1-Lack of time:
When doctors (primary care physician (PCP) or specialist) focus on history and physical exam they can make the diagnosis in 80% of cases. When lack of time is a key factor, physician have to go fast, interrupt their patients, do a rapid physical exam and then relies on investigations in order to get the diagnosis.
2- When people value specialist more than primary care physician more, investigations will be ordered by primary care physician to give the impression that they can act as specialists.
3- Lack of knowledge by doctors when it comes to interpret medical literature: knowing the difference between absolute risk reduction and relative risk reduction, how to calculate number needed to treat and number needed to harm, what is the added value of tests (pretest probability and posttest probability) and the implication of a statistically significant reduction when comparing a treatment to a placebo or to another one …..
4- PCP want to show that they know all the new procedures and imaging as well as new treatments.
5- Doctors try to avoid missing an early diagnosis by fear of lawsuits and tend to ask for more investigations.
6- Difficult and over-demanding patients might need much more than just listening and practicing a physical exam. They often ask for unnecessary tests and imaging, and the encounter with them can be a disaster sometimes.
7- In some countries, doctors receive bonuses from specialized centers on laboratory tests and imaging. This incentive is quite unethical and pushes them to order more investigations in order to raise the alleged bonus.
8- Doctors forgot patient’s anxiety when investigations are prescribed.
9- Sometimes recommendations change with time, patients cannot understand why. For example the cut off of blood pressure was 140/90 and recently it has been modified to 150/90 in adults above 60 years of age; so when we use to insist a year ago to get the measure of blood pressure under 140 we find our self today telling our patients that their blood pressure must be under 150. Blood tests for dyslipidemia while fasting would probably change for checking for dyslipidemia after meal or at any time. Paracetamol used for many years to treat low back pain is no more indicated according to recent data. Doctors themselves have to be convinced by the practice deviations and have to convince their patients that what was applicable a week ago is no more evidence based today.
10- PCPs specifically have to be updated about the new recommendations and organizations have to find a smooth way to implement new guidelines.
11- Patients hardly accept not to take a treatment and once again physicians found themselves offering treatment that are not evidence based. An example is the use of chondroitine and glusosamine in osteoarthritis.
12- Additional interventions could reflect sometimes a variance between PCP and specialist guidelines. A good example is the PSA, urologists order PSA for all male patients while PCP try to limit this exam for those at risks and according to their age. When patients blame their PCP for not checking the PSA while specialist does this will drive PCP to ask this test more frequently forgetting about the harm they are imposing to their patients
The major limitations are lack of time and physician education about recommendations.
Too much medicine is mainly practiced by specialists who order investigations at large and provide treatment under studies. Implementation of guidelines will be easier in primary care setting. Valuing PCP, adjusting encounter time and providing basic statistics information and updated recommendations are the main factors that contribute to the implementation of the program “choosing wisely”.
Competing interests: No competing interests
Dr. A. Malhotra et al. your article is an excellent eyeopener for all !. Every educated and knowledgeable person realizes that doctors are prescribing extra diagnoses.
the culture in corporate and other private hospitals is like this - the doctor takes a consultation of Rs200/- but writes a diagnostic tests costing Rs6000/- or more. so the doctor see's 4-5 patients a day and gets more from commissions. Doctor may be compelled to do this as his performance is judged by the number of patients he see's and orders equal number of diagnostic tests ! this is a vicious circle- how can you stop this ?
It is a horrible situation for all the middle class and poor people.
there should be moderation and doctors should not indulge in such practices. - Making corporates richer and public poorer !
my opinion !
thanks for giving me this opportunity to pen this.
Competing interests: No competing interests
My experience as a GP trainer leads me to observe that, increasingly, younger doctors brought up in a blame culture are less versed in clinical skills and more likely to order investigations, which may then reveal "incidentalomas" requiring further tests. Often, guidelines, which are themselves risk averse, compound the problem by suggesting investigations for a symptom, rather than being tailored to the individual patient. Training rotas which allow trainees to take responsibility for patients throughout their illness journey, and to see how the result of a test ordered affects the outcome for the patient, along with a supportive culture which allows for some tolerance of uncertainty, may help reduce this root cause of overdiagnosis.
Competing interests: No competing interests
Dear Sir,
We welcome the Choosing Wisely initiative in the UK (1). For over 30 years, the nonprofit continuing education organization Prescrire has helped healthcare professionals and patients to choose treatments that minimize the risk of adverse effects, based on strong evidence. And to do that wisely Prescrire includes only editors who are free of conflict of interests with drug companies, government agencies or payers.
Many drugs are approved despite a lack of solid evidence that they are any better than existing treatments, or despite being less effective or more harmful than current options.
Each month Prescrire editors sort out the few drugs that provide an advantage from the majority of new products that are useless or risky, as shown in our annual review (2). From the 87 drugs and indications reviewed in 2014 only 3 “Offered a real advance”, 5 “Offered an advantage”, 15 were “Possibly helpful”. But 35 drugs provided “Nothing new” compared with existing treatments, while 19 were “Not acceptable” (2).
Prescrire also publishes annually a list of “Drugs to avoid”. The 2015 list identified 71 drugs on the French market that are more harmful than beneficial (3). They include drugs with adverse effects that are disproportionate to their benefits, older drugs superseded by new drugs with a better harm-benefit balance, recent drugs that have a less favourable harm-benefit balance than current options, and drugs without proven efficacy but that expose to serious adverse effects.
Globally we all need to make better use of existing treatments. That means to choose, discard and deprescribe.
1- Malhotra A et al Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ 2015;350:h2308 doi: 10.1136/bmj.h2308.
2- Prescrire Editorial Staff “New drugs and indications in 2014” Prescrire Int 2015; 24 (159): 107-110. Free access http://english.prescrire.org/en/81/168/49897/0/NewsDetails.aspx?page=2
3- Prescrire Editorial Staff “Towards better patient care: drugs to avoid in 2015” Prescrire Int 2015; 24 (158): 78-79. Free access http://english.prescrire.org/en/81/168/49828/0/NewsDetails.aspx
Competing interests: No competing interests
Dear Sir,
People receiving unnecessary treatments: accurate diagnosis is key.
Our experience managing people with low back pain supports Malhotra’s view that people receive unnecessary treatments (1). We agree with Malhotra that diagnosis drives treatment. However, we suggest that emphasis needs to be placed on achieving accurate diagnosis rather than identifying, “over-diagnosis”.
Simple logic underpins medical practice. Clinicians are required to make diagnoses. Explicit diagnoses underpin meaningful discussions about management options, their mechanisms of action and their potential risks and benefits. The more certain the diagnosis, the more certain the outcome of a particular intervention.
Consider lumbar nerve root compression (LNRC). Our experience is that LNRC is underdiagnosed, and people with this potentially surgically manageable condition are subjected to a range of unnecessary treatments that are, in this context, of limited value (2). The likely source of LNRC misdiagnosis is two-fold. There is a major discrepancy between the symptoms specialists recognise as potentially attributable to LNRC, and the guidance available to non-specialists (3). At the same time, “non-specific low back pain” (NSLBP), is often managed as a diagnosis when it is in fact a common symptom which will almost certainly have a multitude of potential causes, one of which may be LNRC.
Hookway and colleagues’ article (4) highlighted for us similarities between irritable bowel syndrome (IBS) and non-specific low back pain (NSLBP). Both IBS and NSLBP are very common, have pain as the principle symptom, and are managed largely in primary care. More importantly, both IBS and NSLBP are managed as formal diagnoses supported by NICE guidelines when, in fact, it is more accurate to describe the terms IBS and NSLBP as labels for collections of symptoms which are themselves the final common pathway of a diverse range of origins (5).
The key messages of our own editorial on the problems of definition and diagnosis in back pain apply to IBS and possibly to other areas of medicine (for example, bipolar disorder). We provide evidence to suggest that the current approach to managing low back pain is illogical and the guidelines are not helpful for these complex symptoms (6).
We suggest the way forward may be aided by committees but it is probably more important to:-
• Make sure clinicians have enough time with patients to take an appropriate history.
• Make sure clinicians have sufficient time to keep up to date with available evidence & to engage with clinical research.
• Invest in research measuring the risks and benefits of intervention.
Yours Faithfully,
Tim Germon, Consultant Spine Surgeon
Jeremy Hobart, Professor of Neurology & Clinical Measurement
References
1. Malhotra A. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ 2015;350:h2308 doi: 10.1136/bmj.h2308.
2. AC Dias, DS Jeyaretna, JC Hobart, TJ Germon Treating pain resulting from nerve root compression: a ride on the not so magic roundabout. Journal of Bone & Joint Surgery, British Volume 94 (SUPP X), 061-061.
3. Germon, Tim, William Singleton, and Jeremy Hobart. "Is NICE guidance for identifying lumbar nerve root compression misguided?." European Spine Journal 23.1 (2014): 20-24.
4. Hookway, Cheryl, et al. "Irritable bowel syndrome in adults in primary care: summary of updated NICE guidance." BMJ 350 (2015): h701.
5. Germon Tim, Hobart Jeremy. http://www.bmj.com/content/350/bmj.h701/rr
6. Germon, Timothy J, Hobart, Jeremy C. Definitions, diagnosis, and decompression in spinal surgery: problems and solution. The Spine Journal 2015;15(3):S5 - S8.
Competing interests: No competing interests
Sometimes worlds are more confusing than enlightening. And sometimes this is not a mere matter of chance.
The world “innovation” has justified broad changes in the way medicines were regulated during the last fifteen years by regulation agencies, translating mainly in “flexibility. This means the introduction of accelerated approval in the USA and conditional approval/ authorization in Europe and Japanand marketing processes facilitating marketing of drugs with unproven affectiveness . Steven Morgan, form the UBC, pointed that “The term suggests that the product has unique value. However, notions of value are a matter of perspective.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3091590/ From the pharmaceutical companies perspective “value” means financial value whereas the social value of medical innovation lies in its capacity of improving patient’s health in the real world. Thus, novelty, or technological innovation is not equal to medical innovation and such an important issue remains unclear because there is not a clear definition of what is a medical innovation. When regulatory agencies accept the marketing of new drugs without any proven effectiveness what kind of innovation are they rewarding? Medical or only commercial innovation? This seems an important issue to solve for choosing wisely.
Another major point is the signification of “personalized medicine”. That seems a very attractive concept. We understand that every patient will have the opportunity to receive just the drug he needs and that will then be 100% efficient for him. Unfortunately such a drug doesn’t exist and “personalized medicine” is just a marketing concept. What really exist is “stratified medicine” and that looks much less exciting. To stratify means to subdivide large groups of patients in smaller groups. Generally in personalized medicine this is done throw biomarkers. But with or without biomarkers effectiveness has still to be proven. And splitting groups tends to make it more difficult because the best way to prove effectiveness are randomized controlled trials and in smaller groups the statistical power of RCTs is reduced and less convincing.
These considerations have much to do with the new regulations that are being prepared at the European Medicines agency, which are referred to as “adaptative pathways approach” http://www.ema.europa.eu/ema/index.jsp?curl=pages/regulation/general/gen... . This new approach could rapidly shape all the regulation processes. The exception would then become the rule and could lead to the massive and permanent marketing of new expensive drugs without any proven effectiveness on the basis of their “promising” status http://onlinelibrary.wiley.com/doi/10.1002/cpt.59/pdf . What is a « promising medicine »? This is another world to define.
So far, only medicines considered essential for “unmet needs” can access conditional approval in the UE. Nevertheless the promoters of adaptative pathways, mainly pharmaceutical companies and their cronies, would like to change the concept of “unmet needs” by the concept of “window of opportunity” much more vague and large.
Although adaptative pathway is supposed to apply only to targeted populations the promoters hope that it would soon become the standard “regulation” pathway for new medicines.
We understand how large this concept is, and how large the targeted groups could be when the article makes it clear that, for the Alzheimer’s disease the promoters of the “adaptative pathway” approach think that the patients should be treated (with monoclonal antibodies which are highly toxic drugs) 15 to 20 years before manifestation of clinical symptoms. That means treating all the healthy 40 to 50 years old population, or maybe a more limited group of this population selected by biomarkers just fot the sake of seeing if this would finally bring some reduction of Alzheimer’s disease symptoms for some of them. This would really be an innovative approach to medicine.
This emphasizes the need to clearly define what we are talking about. A first step for choosing wisely.
Competing interests: No competing interests
Like many doctors across the country, I was delighted to see the launch of the UK version of the ‘Choosing Wisely’ campaign by the AoMRC this week (1) and equally disappointed to see the associated newspaper headlines about NHS rationing (2). It is clear to me, as I hope it is to others, that cost savings are actually just a helpful side effect of this initiative and are being given undue attention.
The real heart of the campaign is the increased involvement of the public in their care and the provision of relevant and understandable information to enable individuals to make informed choices. It highlights the important principles of person-centred care and shared decision-making that are increasingly becoming embedded in healthcare policy and practice (3, 4).
We should certainly be adopting this campaign in the UK but I suggest we alter the name that was used in the US and Canadian versions. I propose we opt instead for ‘Choosing Together’. This more accurately reflects the mission statement and makes for a more compelling offer to those that it’s really calling to.
1. Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M et al. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine BMJ 2015; 350 :h2308
2. The Guardian. Doctors to withhold treatments in campaign against 'too much medicine'. Available at: http://www.theguardian.com/society/2015/may/12/doctors-to-withhold-treat...
3. Richards T, Coulter A, Wicks P. Time to deliver patient centred care. BMJ. 2015 Feb 10;350:h530.
4. Agoritsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl EA, Neumann I, Tikkinen KA, Weijden Tv, Elwyn G, Montori VM, Guyatt GH, Vandvik PO. Decision aids that really promote shared decision making: the pace quickens. BMJ. 2015 Feb 10;350:g7624.
Competing interests: No competing interests
Re: Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine
I fully support Dr Sehmi’s points. As a patient this report, short though it is, raises issues that I have questioned in the past.
“This list acts as an important reminder that reviewing current practice in medicine is important, not just because it can help us improve on good and bad experiences, but also because sometimes habits form with little justification for them.”
And
Surely NHS leaders and healthcare professionals should have considered cost saving measures like this early on? If this advice is so obvious to healthcare professionals, why was more not done before this point to rectify the situation?”
May I suggest that this may be due in part to the DIRECTIVES (aka guidelines) that promote these procedures and second to the potential action of the GMC to those who have the audacity to challenge the conventional “gospel”
The report itself identifies another problem, namely: What is much more important is that both doctors and patients really question whether the particular treatment is really necessary.
The problem with this solution is that it really challenges the DIRECTIVEs and the GMC and its archaic views of itself.
The sooner the medical establishment frees itself from Big Pharma domination and truly examines the real benefits and harms of its armoury of drugs the better. An example of Big Pharma’s attitude is given in Gigerenzer’s book Risk Savvy: How To Make Good Decisions (p. 165) “After my first CME lecture, a representative of the industry (BP) approached me: “Very helpful,” he commented, “but we will of course go on using relative risks for advertising benefits.” In short inflated results are good for advertising.
Nowadays it seems that much medical therapeutic research is only concerned with the inflated benefits provided by OR/HR analyses though in most cases the use real values when it comes to adverse reactions. One has only to look at drug data inserts where “side effects”, a euphemism used instead of “adverse effects” to see that these are always given in real terms for confirmation of this assertion.
I have in the past supported the concept of patient involvement in his/her personal treatment. I suspect that many GPs, “junior doctors”(??) and consultants working daily and face to face feel the same. Such practice I believe improves their “placebo effect” (bedside manner) and confidence in the doctors’ themselves.
Competing interests: No competing interests