Three very good questions we might, as patients, ask our doctors when offered a test or a Something done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. More are ‘is it supported by evidence?’, ‘could it harm me?’ and ‘is it necessary?’ These questions are at the heart of the Choosing Wisely initiative, developed in the US and Canada and launched this week here in the UK. It’s all about identifying common interventions that are of questionable value, which we might be better off not having, with a spotlight on the top five in each speciality.
We need to change the ‘do something’ culture
We’ve got ourselves into a bad place. As Dr Malhotra and colleagues put it in their BMJ article on Choosing Wisely, ‘a culture of “more is better”, where the onus is on doctors to “do something” at each consultation has bred unbalanced decision making’. People are being overtreated, offered tests or treatments that have little (or no) evidence to support them, minimal benefit and considerable potential for harm, along with making a dent in the budget.
Of course, it’s easy for this to be presented primarily as a money saving exercise, but this isn’t about spending less; it’s about spending wisely and reducing waste. As Charles Cleland, a doctor at Sunderland Royal Hospital, responded: ‘in a health system with finite resources, the over investigation and over treatment of patients is not just wasteful, it also detracts from the ability of the system to provide adequate care to the next patient. It can also, more directly, lead to negative health consequences’.
What’s more, sometimes doing nothing is going to be the best option from the patient’s perspective. Dr Richard Lehman, BMJ author and shared decision-making advocate, who helps us look at the implications for practice of new Cochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More, takes this up:
‘This could be the biggest step towards patient-centred medicine in the UK or it could fizzle out in a lot of arguments about this treatment and that. The only way it can succeed is if it genuinely involves patients at every stage and every level. Already the Guardian correspondent has chosen to paint it as another exercise in top-down rationing. It is the very opposite. It’s trying to get doctors to have a better understanding of the real benefits and harms of treatments and care pathways and how to explain and discuss these with people in a way that meets their concerns, goals and preferences’.
‘And we’re a long way from knowing how best to do that, so part of the effort must be to find out how decisions and uncertainties are best discussed, not as a tick-box exercise but in a real dialogue. That means looking at how the evidence fits the patient and not the other way round. It means explaining how leaving time to see how things develop may often be better than rushing into treatment. It means establishing mutual trust and treating guidelines as advice and not as tramlines. We need to re-establish the value of wisdom and kindness and look at how best to teach and disseminate these, as well as teaching and disseminating the best evidence to guide practice’.
What is being called for here is a culture change in health care that puts the patient centre stage and works in partnership with patients to achieve it. This isn’t new but it is essential to the aims of Choosing Wisely. Good communication is vital at every stage; ‘questioning’, ‘understanding’ and ‘discussion’ are words that leap out from the writings of this initiative’s exponents. They also call for resources to help clinicians and patients alike to understand evidence.
How can Cochrane help?
Cochrane UK’s Director Martin Burton said:
‘My colleague Dr Al Mulley – a world-leader in shared decision-making – very wisely talks about patients having the treatments they “want and need, no more, no less”. Cochrane seeks to help people make the sort of informed decisions that underpin this strategy’.
Producing and sharing the best available evidence to inform decisions about treatment is precisely what Cochrane is all about and Cochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More, along with other high quality evidence, are helping to identify interventions we might be better off without. Here are some examples (and there are many more) of Cochrane evidence that’s already been called on in the US and Canada by those asking clinicians and patients to choose wisely.
- Citing this Cochrane review, Choosing Wisely Canada recommends that people with type 2 diabetes who are not using insulin should not routinely monitor their blood glucose levels. The evidence shows that monitoring has little effect on blood sugar control and there’s no evidence of an effect on people’s health-related quality of life and general wellbeing.
- In the US, this Cochrane review and other evidence underpins the Choosing Wisely recommendation that help with eating by mouth should be offered to people with advanced dementia, rather than feeding through a tube inserted into the stomach, as this doesn’t seem to offer benefits and has been associated with harms, including pressure ulcer development, distress and the use of restraints.
- A health condition (or episodes of a health condition) that comes on quickly and is short-lived. More sinusitis results in 16 million visits to the doctor each year in the US and $5.8 billion in annual health care costs. Most will have sinusitis due to a viral infection that will resolve on its own. The recommendation there is now that antibiotics should not be routinely prescribed for acute mild-to-moderate sinusitis in the first week. Choosing Wisely cites this Cochrane review, which highlighted the need for the small benefits of antibiotic treatment to be weighed against the potential harms, for both the individual and the The group of people being studied. Populations may be defined by any characteristics e.g. where they live, age group, certain diseases. More.
The latest Cochrane review which caught our attention for highlighting the questionable value of a treatment was this one on percutaneous vertebroplasty for vertebral compression fractures in people with osteoporosis. This involves injecting medical grade cement into a fractured vertebra. Moderate quality evidence shows that it has no more Clinical significance is the practical importance of an effect (e.g. a reduction in symptoms); whether it has a real genuine, palpable, noticeable effect on daily life. It is not the same as statistical significance. For instance, showing that a drug lowered the heart rate by an average of 1 beat per minute would not be clinically significant, as it is unlikely to be a big enough effect to be important to patients and healthcare providers. More benefits than a fake procedure and has the potential for serious harms, including spinal cord or nerve root compression due to cement leakage, cement emboli into the lungs and large vessels, rib fractures, osteomyelitis, fat embolism, thecal sac injury, anaesthetic complications and death.
Effective communication is essential
Just as important as producing high quality evidence is to share it in ways that are accessible and useful to as many people as possible. I’ve written very recently here about why I think blogs are a good way to share evidence, just one amongst many ways Cochrane disseminates evidence, from plain language summaries and podcasts, many available in a range of languages, to a new initiative to present review findings visually as infographics. For the Choosing Wisely programme in the UK, the biggest challenge perhaps lies in getting clinicians and patients to have ‘Choosing Wisely’ conversations. I wrote a blog a while ago about Cochrane evidence showing that decision aids can help people make better choices and improve communication with their practitioner, which also includes a video showing a decision aid being used in a consolation. In that blog, Richard Lehman comments that shared decision-making and patient-centred evidence is the unicorn not yet found. Let’s hope Choosing Wisely takes us all a step closer to achieving those goals.
I leave you with a video from the wonderful James McCormack, who knows a thing or two about making evidence based healthcare concepts engaging and accessible, on Choosing Wisely.
Malhotra A, Maughan D, Ansell J, Lehman R, Henderson A, Gray M, Stephenson T, Bailey S. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ 2015;350:h2308. Available from: http://www.bmj.com/content/350/bmj.h2308.full.pdf+html
Malanda UL, Welschen LMC, Riphagen II, Dekker JM, Nijpels G, Bot SDM. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database of In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More 2012, Issue 1. Art. No.: CD005060. DOI: 10.1002/14651858.CD005060.pub3.
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007209. DOI: 10.1002/14651858.CD007209.pub2
Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub3.
Buchbinder R, Golmohammadi K, Johnston RV, Owen RJ, Homik J, Jones A, Dhillon SS, Kallmes DF, Lambert RGW. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD006349. DOI: 10.1002/14651858.CD006349.pub2.