Helping patients choose wisely

New UK recommendations emphasise shared decision making

As the tree of overdiagnosis has grown, efforts have been made to trim the branches. Initiatives such as Preventing Overdiagnosis, Too Much Medicine, Slow Medicine aim to increase our understanding of how it manifests itself. Efforts such as Choosing Wisely are underway to affect policy and change patient expectations and to change well-entrenched medical practices.

Abstract

Overdiagnosis and overtreatment are common, harmful to patients, and expensive. Doctors and patients tend to overestimate the benefit and underestimate harm of interventions. Choosing Wisely is a medically led campaign focusing on engaging doctors and patients in decisions about potentially unnecessary medical tests, treatments, and procedures. It started in the US in 2012 and has now been taken up in 22 countries worldwide, including the UK.

Read the full text on The BMJ, 2018.

“Helping patients choose wisely”

This statement grandly assumes that patients have no wisdom. Whilst it might well apply to many patients, there are equally many who are very well aware and informed of the best course of action to be taken.

bm Patient Karyse Day’s response, 2018.

Does a prediabetic condition increase the risk of developing (type 2) diabetes ?

Development of type 2 diabetes mellitus in people with intermediate hyperglycaemia (‘prediabetes’)

A war on “prediabetes” has created millions of new patients and a tempting opportunity for pharma. But how real is the condition, and is it good medicine?

2018 Study Abstract

Review question
We wanted to find out whether raised blood sugar (‘prediabetes’) increases the risk of developing type 2 diabetes and how many of these people return to having normal blood sugar levels (normoglycaemia). We also investigated the difference in type 2 diabetes development in people with prediabetes compared to people with normoglycaemia.

Background
Type 2 diabetes is often diagnosed by blood sugar measurements like fasting blood glucose or glucose measurements after an oral glucose tolerance test (drinking 75 g of glucose on an empty stomach) or by measuring glycosylated haemoglobin A1c (HbA1c), a long-term marker of blood glucose levels. Type 2 diabetes can have bad effects on health in the long term (diabetic complications), like severe eye or kidney disease or diabetic feet, eventually resulting in foot ulcers.

Raised blood glucose levels (hyperglycaemia), which are above normal ranges but below the limit of diagnosing type 2 diabetes, indicate prediabetes, or intermediate hyperglycaemia. The way prediabetes is defined has important effects on public health because some physicians treat people with prediabetes with medications that can be harmful. For example, reducing the threshold for defining impaired fasting glucose (after an overnight fast) from 6.1 mmol/L or 110 mg/dL to 5.6 mmol/L or 100 mg/dL, as done by the American Diabetes Association (ADA), dramatically increased the number of people diagnosed with prediabetes worldwide.

Study characteristics
We searched for observational studies (studies where no intervention takes place but people are observed over prolonged periods of time) that investigated how many people with prediabetes at the beginning of the study developed type 2 diabetes. We also evaluated studies comparing people with prediabetes to people with normoglycaemia. Prediabetes was defined by different blood glucose measurements.

We found 103 studies, monitoring people over 1 to 24 years. More than 250,000 participants began the studies. In 41 studies the participants were of Australian, European or North American origin, in 7 studies participants were primarily of Latin American origin and in 50 studies participants were of Asian or Middle Eastern origin. Three studies had American Indians as participants, and one study each invited people from Mauritius and Nauru. Six studies included children, adolescents or both as participants.

This evidence is up to date as of 26 February 2018.

Key results
Generally, the development of new type 2 diabetes (diabetes incidence) in people with prediabetes increased over time. However, many participants also reverted from prediabetes back to normal blood glucose levels. Compared to people with normoglycaemia, those with prediabetes (any definition) showed an increased risk of developing type 2 diabetes, but results showed wide differences and depended on how prediabetes was measured. There were no clear differences with regard to several regions in the world or different populations. Because people with prediabetes may develop diabetes but may also change back to normoglycaemia almost any time, doctors should be careful about treating prediabetes because we are not sure whether this will result in more benefit than harm, especially when done on a global scale affecting many people worldwide.

Certainty of the evidence
The certainty of the evidence for overall prognosis was moderate because results varied widely. The certainty of evidence for studies comparing prediabetic with normoglycaemic people was low because the results were not precise and varied widely. In our included observational studies the researchers often did not investigate well enough whether factors like physical inactivity, age or increased body weight also influenced the development of type 2 diabetes, thus making the relationship between prediabetes and the development of type 2 diabetes less clear.

Authors’ conclusions:
Overall prognosis of people with IH worsened over time. T2DM cumulative incidence generally increased over the course of follow-up but varied with IH definition. Regression from IH to normoglycaemia decreased over time but was observed even after 11 years of follow-up. The risk of developing T2DM when comparing IH with normoglycaemia at baseline varied by IH definition. Taking into consideration the uncertainty of the available evidence, as well as the fluctuating stages of normoglycaemia, IH and T2DM, which may transition from one stage to another in both directions even after years of follow-up, practitioners should be careful about the potential implications of any active intervention for people ‘diagnosed’ with IH.

To be prediabetic : a (very) questionable condition

A third of Americans are considered prediabetic – but many may be better off without treatment

A war on “prediabetes” has created millions of new patients and a tempting opportunity for pharma. But how real is the condition, and is it good medicine?

“Practitioners should be careful about the potential implications of any active intervention for people ‘diagnosed’ with intermediate hyperglycaemia (‘prediabetes’)” cochrane.

Où en est la médecine basée sur les preuves ?

EBM et maladies chroniques

Publié par Luc Perino, médecin généraliste, humeur du 26/02/2019

« EBM » est le sigle de « evidence based medicine » ou « médecine basée sur les preuves ». Ce concept promu dans les années 1960 recèle une insulte envers nos ancêtres médecins. Tous les diagnostics étaient déjà basés sur de solides preuves depuis la méthode anatomoclinique qui a fondé la médecine moderne dans les années 1800. La majorité des médicaments efficaces (insuline, antibiotiques, corticoïdes, aspirine, vitamines, vaccins, héparine, morphine, diurétiques, neuroleptiques, etc.) ont été découverts avant l’EBM.

S’arroger ainsi une rigueur qui existait depuis longtemps est une impudence qui peut cependant s’expliquer. Auparavant, la médecine gérait des pathologies monofactorielles dont les symptômes étaient vécus (infections, traumatismes, carences, épilepsie, etc.). Puis, au cours du XX° siècle, elle s’est intéressée à des maladies plurifactorielles : tumorales, neurodégénératives, immunologiques, psychiatriques, métaboliques et cardiovasculaires. Toutes caractérisées par une évolution lente et des symptômes erratiques rendant la preuve empirique impossible. Comment prouver que détruire quelques cellules cancéreuses, faire baisser la pression artérielle ou le cholestérol augmente la quantité-qualité de vie ?
Pour convaincre les médecins et les patients, il fallait remplacer la preuve individuelle vécue par une preuve populationnelle et probabiliste. L’idée était bonne, l’outil statistique valide et le paradigme séduisant. C’est pourquoi, depuis un demi-siècle, l’EBM et ces maladies dites « chroniques » monopolisent la pensée médicale.

Il est temps d’oser quelques raisonnables critiques.

  • Définir une maladie aux symptômes concrets était déjà difficile, c’est désormais impossible puisqu’une majorité de ces « maladies chroniques » ne sont jamais vécues (hypertension, hyperglycémie, cancer dépisté, etc.).
  • Les gains de quantité de vie sont négligeables et souvent non évaluables (le traitement d’une hypercholestérolémie par statine ne peut rivaliser avec celui du scorbut par la vitamine C ou d’une septicémie par la pénicilline)
  • Les gains de qualité de vie sont nuls ou négatifs (l’annonce d’un cancer non vécu est une perte, alors que la suppression des délires par un neuroleptique était un gain pour le patient et sa parentèle)
  • Les statistiques et publications ont accumulé des biais et tricheries si effarants que toute la pratique médicale en devient suspecte.

Considérons encore plus pragmatiquement l’échec global sur ces « maladies chroniques ». Si la médecine peut être fière d’avoir supprimé la variole, le pied-bot et le bégaiement, elle ne le peut pas pour des maladies dont la prévalence augmente (Alzheimer, myopie, obésité, cancer ou dépression). Même si certains facteurs sont sociétaux, cela reste un échec pour ceux qui en revendiquent la charge.

Enfin, reprocher le diagnostic trop tardif de maladies chroniques est antinomique, voire ubuesque. Après avoir insulté les médecins du passé, l’EBM récidive avec ceux d’aujourd’hui.

En Savoir Plus

En médecine aussi, le mieux est l’ennemi du bien

Consistance des maladies virtuelles

Publié par Luc Perino, médecin généraliste, humeur du 31/10/2018

La morbidité se définit comme

  • un “état de maladie
  • ou un “caractère relatif à la maladie“.

Ces définitions sous-entendent que la morbidité est vécue par le patient avant d’être comptabilisée par la médecine. La troisième définition est statistique :

  • pourcentage de personnes atteinte d’une maladie donnée“.

Désormais, la médecine se propose d’intervenir avant les premiers signes de maladie. Le dépistage organisé et la détection des facteurs de risque créent ainsi une nouvelle morbidité qui n’est plus vécue par les patients. Une image suspecte, une cellule anormale, une prédisposition génétique, un chiffre élevé de pression artérielle, de sucre ou de cholestérol ne sont pas des signes ressentis par le patient mais des informations qu’il reçoit de la médecine. Cette morbidité est donc virtuelle pour le patient.

Si je peux comprendre l’intérêt de la biomédecine pour ces maladies virtuelles, je suis toujours surpris de la docilité avec laquelle ces patients “virtuels” acceptent ces nouveaux diagnostics et les vivent comme des maladies dont ils auraient réellement ressenti les symptômes. Ils les vivent même parfois avec une intensité dramatique supérieure à celle d’une maladie réellement vécue.

Pourtant, un grand nombre d’images ou de chiffres suspects, disparaissent comme ils apparaissent sous l’effet de multiples facteurs variables et labiles. On peut être hypertendu pendant deux ans et ne plus l’être pour tout le reste de sa vie. On peut avoir une cellule cancéreuse sans que jamais n’apparaisse ni tumeur ni métastase. Dans leur grande majorité, les prédispositions génétiques restent indéfiniment à l’état de prédisposition.

Le plus surprenant est la définition rétrospective de ces virtualités à partir d’une proposition théorique de soin. C’est exclusivement l’idée d’un soin qui leur confère une réalité morbide.
Cette inversion complète des processus diagnostiques et thérapeutiques répond merveilleusement aux nouvelles normes mercatiques et informatiques de notre monde auxquelles la médecine n’a pas de raison d’échapper. Ce n’est plus le patient qui vient proposer au médecin des symptômes vécus dans l’espoir qu’il ne s’agisse pas d’une vraie maladie, ce sont les médecins qui proposent des pathologies virtuelles que le patient va alors vivre comme de vrais maladies.

Avec cette nouvelle normativité, aura-t-on encore besoin de l’expertise clinique des médecins ? Si oui, quel sera alors l’utilité de ces nouveaux experts ? Nous avons de bonnes raisons de penser que leur rôle principal consistera à dissimuler un diagnostic de maladie virtuelle lorsqu’ils estimeront que le fait de la donner à “vivre” pourrait dégrader la santé plus que ne le ferait la maladie réelle supposée évitable…
Vaste programme à inscrire d’urgence dans le cursus universitaire médical…

En Savoir Plus

Overtreatment : When Medicine Does More Harm Than Good

Why do millions of people a year get tests and procedures that they don’t really need ?

Researchers estimate that 21% of medical care is unnecessary.

Kaiser Health News senior correspondent Liz Szabo moderated a discussion a panel of experts to explore overtreatment.

KHN panelists were:

  • Dr. Louise Davies, An associate professor of otolaryngology – head and neck surgery in The Dartmouth Institute for Health Policy & Clinical Practice
  • Dr. Saurabh Jha, an associate professor of radiology at the University of Pennsylvania
  • Dr. Barry Kramer, director of the division of cancer prevention at the National Cancer Institute
  • Dr. Jacqueline Kruser, a pulmonologist and critical care physician at Northwestern University Feinberg School of Medicine
  • Dr. Ranit Mishori, professor of family medicine at the Georgetown University School of Medicine.
  • Reference.
  • Video source : KHN was live.

Is cancer fundraising fuelling quackery ?

Are crowdfunding sites promoting quack treatments for cancer ?

Figures published by The BMJ show how crowdfunding for alternative therapies for patients with terminal cancer has soared in recent years. But there are fears that huge sums are being raised for treatments that are not backed by evidence and which, in some cases, may even do then harm, MedicalXpress reports.

JustGiving’s own figures show more than 2300 UK cancer related appeals were set up on its site in 2016, a sevenfold rise on the number for 2015.

The phenomenon has allowed less well-off patients to access expensive, experimental treatments that are not funded by the NHS but have some evidence of benefit. But many fear it has also opened up a new and lucrative revenue stream for cranks, charlatans, and conmen who prey on the vulnerable.

“We are concerned that so many UK patients are raising huge sums for treatments which are not evidence based and which in some cases may even do them harm.”

The society’s project director, Michael Marshall, said.

Melanie Newman, freelance journalist, London, UK, examines calls to help ensure patients and their donors are not being exploited.

Featured image credit @bmj_company.

Drop the C-word to reduce anxiety and overtreatment, say experts

Renaming low risk conditions labelled as cancer

Removing the cancer label in low risk conditions that are unlikely to cause harm if left untreated may help reduce overdiagnosis and overtreatment, argue The BMJ

Abstract

Evidence is mounting that disease labels affect people’s psychological responses and their decisions about management options. The use of more medicalised labels can increase both concern about illness and desire for more invasive treatment. For low risk lesions where there is evidence of overdiagnosis and previous calls to replace the term cancer, we consider the potential implications of removing the cancer label and how this may be achieved.

Our changing understanding of the prognosis of cancers

Some cancers are non-growing or so slow growing that they will never cause harm if left undetected. A prime example is low risk papillary thyroid cancer. Autopsy studies show a large reservoir of undetected papillary thyroid cancer that never causes harm, and the incidence of thyroid cancer has risen substantially in many developed countries. This rise has been predominantly driven by an increase in small papillary thyroid cancers, with mortality remaining largely unchanged. These small papillary thyroid cancers are increasingly being detected because of new technologies, increased access to health services, and thyroid cancer screening. Studies show that rates of metastases, progression to clinical disease, and tumour growth in patients with small papillary thyroid cancer who receive immediate surgery are comparable with those in patients who follow active surveillance.

Likewise, for both low risk ductal carcinoma in situ (DCIS) and localised prostate cancer, detection strategies have become controversial as long term outcomes for both conditions have been shown to be excellent and there is evidence and concern about overdiagnosis and overtreament. Given the potential harms of overtreatment of DCIS, active surveillance is now being trialled internationally as an alternative approach. …

continue reading Renaming low risk conditions labelled as cancer on The BMJ, 12 August 2018. Image  credit @bmj_company.

Too Much Medicine Helsinki Symposium 2018

Paulo Foundation International Medical Symposium, Helsinki, 15 – 17 Aug 2018

Abstracts

  • Overestimation of depression prevalence in meta-analyses via the inclusion of primary studies that assessed depression using screening tools or rating scales rather than validated diagnostic interviews
  • Clinician, patient and general public beliefs about diagnostic imaging for low back pain: A qualitative evidence synthesis
  • Overdiagnosis of low back pain
  • Defining Overdiagnosis of Mental Health Disorders: Secondary Analysis of an Overdiagnosis Scoping Review
  • Evaluating the content of Choosing Wisely recommendations and prevalence of interdisciplinary finger pointing
  • Inadequate Prescription of medicines for Parkinson’s disease in the Autonomous Community of the Basque Country. An observational study
  • Is it always necessary to treat nocturia? Natural history of nocturia among men and women during the 5-year period
  • The monocriterial source of over-testing and over-treatment: the case of bone scanning
  • Increasing prescription of opioid analgesics and neuropathic pain medicines for spinal pain in Australia
  • No benefit of additional care for ‘high-risk’ patients with acute low back pain: The PREVENT randomized, placebo-controlled trial
  • Overdiagnosis, overtreatment and low-value care in physiotherapy: a scoping review
  • Targeted information based on reimbursed drug registry
  • Journal Registration Policies and Prospective Registration in Randomized Trials of Non-Regulated Interventions: A Meta-Research Review
  • Pharmacotherapy and behavioural problems in Autism Spectrum Disorders
  • Simultaneous under and over care of eye health care in Finland
  • Decision Support and Knowledge Translation Tools to Highlight the Benefits and Downstream Harms of Screening: Resources from the Canadian Task Force for Preventive Healthcare
  • A Free Access Literature Awareness Portal That Surveilles High Quality Research and Guidelines to Inform Benefits and Downstream Harms of Screening and Prevention Strategies in Healthcare
  • From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in Finnish health care system
  • Does the use of CAM reflect a patients´ response to “too much medicine”?
  • Preferred Reporting Items for Overview of Systematic Reviews for abstracts (PRIO-abstracts)

Reference.

Is early detection always the best medicine ?

The Recommended Dose, with Alexandra Barratt

Hosted by acclaimed journalist and health researcher Dr Ray Moynihan, The Recommended Dose tackles the big questions in health and explores the insights, evidence and ideas of extraordinary researchers, thinkers, writers and health professionals from around the globe. The series is produced by Cochrane Australia and co-published with the BMJ.

Press Play > to listen to the recording.

Dr Ray Moynihan’s guest has led something of a double life, using both medicine and the media to explore and promote the critical role of evidence in healthcare. Now based at the University of Sydney, Alexandra Barratt‘s journey from clinician to journalist to global advocate for evidence based medicine and shared decision-making is a fascinating one.

Here Alexandra talks with Ray about her varied career and the reasons she’s ended up challenging conventional wisdom. She also talks about her research into the pros and cons of breast cancer screening and questions the widely-accepted idea that early detection is always the best medicine.

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