Making headway against low value services

MJA Insight, 13 February 2017
Author: Nicole Mackee
“The push to address the use of low value, or potentially harmful, medical services is continuing to gain pace in Australia, say experts, after the Lancet published an article describing the overuse of medical services worldwide. Professor Adam Elshaug, professor of Health Policy at the University of Sydney, codirector of the Menzies Centre for Health Policy and a coleader of a Lancet series, Right Care, said Australia’s clinical community had pulled together to drive initiatives aimed at tackling inappropriate care.”
Find article here.

Breast screening benefits have been overstated, Danish study finds

BMJ 2017; 356:j94
Author: Jacqui Wise
“Seventeen years of organised breast screening in Denmark has not reduced the incidence of advanced tumours but has markedly increased the incidence of non-advanced tumours and ductal carcinoma in situ, research published in the Annals of Internal Medicine has shown.”
Find article here.

MP and former GP challenges Uruguay’s compulsory breast screening programme

BMJ 2016;355:i6624
Author: Sophie Arie
“Uruguay’s government is being challenged to end its compulsory breast screening programme, after a court ruled that one woman with concerns about possible harms caused by mammography should be exempt. On 6 December Daniel Radio, a deputy in the opposition Independent party and a former GP, presented a bill to parliament for legislation to ensure that women are asked for their informed consent to undergo screening for breast cancer and are not penalised if they refuse to give it.”
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Overdiagnosis of Coronary Artery Disease Detected by Coronary Computed Tomography Angiography

JAMA Intern Med. 2016;176(12):1747-1748.
Authors: Torrey Schmidt, Ronald Maag, Andrew J. Foy
“Given that the patient was asymptomatic and that the data showing benefit of CABG over medical therapy is decades old, the patient likely should have been treated with medical therapy. Even in patients with diabetes and symptomatic CAD in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, CABG did not improve survival compared with an initial strategy of medical therapy but was associated with a 9% absolute reduction in the composite primary end point of death, myocardial infarction, or stroke over 5 years of follow-up. This patient was not representative of BARI 2D participants, and because his risk would be lower, the expected benefits of CABG would be as well.”
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Physician Recommendations Trump Patient Preferences in Prostate Cancer Treatment Decisions

Med Decis Making vol. 37 no. 1 56-69
Authors: Karen A. Scherr, Angela Fagerlin, Timothy Hofer et al
“Patients’ treatment decisions were based largely on urologists’ recommendations, which, in turn, were based on medical factors (age and Gleason score) and not on patients’ personal views of the relative pros and cons of treatment alternatives.”
Find abstract here.

Royal colleges issue list of 40 unnecessary interventions

BMJ 2016; 355: i5732
Author: Ingrid Torjesen
“The Academy of Medical Royal Colleges has issued a list of 40 tests, treatments, and procedures that it says are of little or no benefit to patients. The list has been created by the academy’s member royal colleges and faculties, with input from patient groups and the National Institute for Health and Care Excellence, and released to mark the launch of the academy’s Choosing Wisely campaign, which includes advice about treatments for doctors and patients.”
Find article here.

Ovarian Cancer Screening Tests Don’t Pass Muster

JAMA. 2016;316(15):1538.
Author: Rebecca Voelker
“Physicians and their women patients shouldn’t use screening tests that claim to detect ovarian cancer, the FDA has cautioned. “Despite extensive research and published studies, there are currently no screening tests for ovarian cancer that are sensitive enough to reliably screen for ovarian cancer without a high number of inaccurate results,” FDA officials said in a statement.”
Find article here.

Solving the Problem of Overdiagnosis

N Engl J Med 2016; 375:1483-1486
Author: Joann G Elmore
“My patients’ fear of breast cancer is palpable. I see them fret over whether or not to have a mammogram, worry about false positive abnormalities, and struggle to pay for diagnostic evaluations for which they are not reimbursed. This collateral damage of screening is obvious to clinicians. However, increasing evidence now indicates a less obvious outcome of cancer screening — overdiagnosis of diseases that would never cause symptoms or death. The presence and effects of overdiagnosis are less tangible, buried in population statistics rather than patient encounters.”
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An empirical study of the ‘underscreened’ in organised cervical screening: experts focus on increasing opportunity as a way of reducing differences in screening rates

BMC Medical Ethics 2016 17:56
Authors: Jane Williams, Stacy M Carter
“Cervical cancer disproportionately burdens disadvantaged women. Organised cervical screening aims to make cancer prevention available to all women in a population, yet screening uptake and cancer incidence and mortality are strongly correlated with socioeconomic status (SES). Reaching underscreened populations is a stated priority in many screening programs, usually with an emphasis on something like ‘equity’. Equity is a poorly defined and understood concept. We aimed to explain experts’ perspectives on how cervical screening programs might justifiably respond to ‘the under screened’.”
Find article here.

From Choosing Wisely to Practicing Value—More to the Story

JAMA Intern Med. 2016;176(10):1571-1572.
Authors: Anna L. Parks, Patrick G. O’Malley
“Since 2012, the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely initiative has targeted low-value care by creating lists of wasteful interventions and disseminating them to physicians and patients. Its original goal was to promote conversation about risks and benefits to prevent unnecessary tests and procedures. In practice, we have witnessed integration of Choosing Wisely principles into hospital-wide quality improvement projects to reduce blood draws, electronic medical record (EMR) alerts about stress ulcer prophylaxis, individualized data about use of telemetry, and even bonuses for achieving high-value goals. Will these efforts be enough to change the culture of how we practice?”
See abstract here.