Download Dr John Bonning, Executive Committee member, CMC

Over-diagnosis
Our ability to help the sick/injured
is soon to be outstripped by
our propensity to harm the healthy.
Underlying principles of choosing wisely
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Rationalising, not rationing - quality, not cost
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Danger of over-diagnosis and over-treatment
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Involve the public early
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Identify “low value care” or even “harmful care”
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Re-invest value healthcare
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DOn’t just make a list, do something!
Enthusiasm for diagnosis
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Engine warning lights/sensors
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Living longer yet sicker. Or being told you are sick.
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Treating people with no symptoms or consequences
can only be harmed by treatment
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Errors of omission vs errors of commission
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Incidentalomas - cost of pan scans in trauma
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Screening low-risk populations - breast, prostate
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More and more sensitive scanners/tests
The Americans have got it so wrong
The Americans have got it so wrong
Blood testing
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Applying a non-specific test to a low risk population…
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d-dimer
troponin
PSA
exercise treadmill tests - infinite NNT in low risk CP
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…will cause more harm than benefit
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you don’t have to diagnose every PE, just the ones that count
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Cost of a CTPA - $$, time, radiation, worry, over-diagnosis
Morbidity and mortality of the treatment
How harmful could a set of LFTs be? Fatal?
Hypertension
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Taking medication when asymptomatic
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Balance risk of harm vs chance of benefit
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Evidence for treatment of severe diastolic (115-130) hypertension
is compelling - adverse outcome (stroke, MI, death)
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Chance of benefit drops drastically as diastolic BP does:
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after 5yrs with Rx is 8%, without Rx 80%. relative benefit 72%, NNT 1.4
after 10yrs with Rx is 15%, without Rx 95%. 5yr group
Severe (115-130) 72% NNT 1.4
Moderate (105-115) 26% NNT 4
Mild (100-105) 9% NNT 11
Very mild (90-100) 6% NNT 18
Systolic hypertension can be an issue in the elderly, but Rx only
reduces the chance of serious outcome at 5yrs from 18% to 13%
so relative benefit 5% & NNT 1/0.05 or 20
Statins
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In patients with known heart disease
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In patients without known heart disease
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zero were helped (life saved) - NNT infinite
1 in 104 were helped preventing non fatal MI
1 in 154 were helped (preventing stroke)
In both groups
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1 in 83 were helped (life saved)
1 in 39 were helped preventing non fatal MI
1 in 139 were helped (preventing stroke)
1 in 100 were harmed (developed diabetes)
1 in 10 were harmed (muscle aches)
Lipitor - the biggest selling drug. Ever.
Big (bad?) Pharma
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Lipitor (Pfizer)
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US$131,000,000,000 in cumulative sales whilst on patent
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Omeprazole made AstraZenica $5billion pa
• Esomeprazole (left isomer) also makes US$5b pa
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Plavix (Bristol-Myers Squibb and Sanofi-Aventis)
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Big Pharma doesn’t like cures, it likes treatments
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2001-2006 US$350m in DTC advertising
US$42.8b during 15yrs under patent
Dyslipidaemia, hypertension, IGT, dyspepsia
Biologic medications made from live cell cultures, as opposed to in the lab, for example Chinese
hamster ovary cells…
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25% of the $320b US spends pa on pharmaceuticals
Humira ($4.8b in 2013) for RA, ank spond, Crohns etc
Enbrel also for auto-immune disease - $1500. per month.
Marketed by Phil Mickelson. It might improve your golf…
Infinite NNTs
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Anything but analgesia for back pain
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do 100% of 50 year olds have bulging discs?
no evidence for back surgery in sciatica
no evidence of benefit of epidural steroid injections
Antibiotics for
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URIs, abscess, sinusitis, uncomplicated wounds
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COX II scandal
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HRT - for every 10,000
• More: 8 breast cancers, 7 MIs, 8 CVAs, 8VTEs
• Fewer: 75% hot flushes, 6 colo-rectal Ca, 5 hip #s, 6 back #s
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Insulin infusions (outside of DKA/ICU settings)
CT scans
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More sensitive scanners find more non-disease - lakes in Scandinavia
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Incidentalomas in pan-scans - 1000 subjects having pan-scans, 86%
had an ‘abnormality’
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gallstones, thyroid/adrenal nodules, cysts in kidneys, liver, ovaries, bulging discs
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Current strategy of investigating and treating PEs in the US is killing 6x
more patients than it is saving
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50% of smokers have lung nodules
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10yr cancer risk in 58yo is 1.8% so maximum chance incidental nodule is cancer is 3.6%
Brian Mulroney - cost of a “routine scan”
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In 1 study 87% of subjects with a cold had ‘CT evidence’ of sinusitis
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Radiation doses - 1 CT chest is
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400 CXRs, 3.6yrs background rad, 40,000km highway driving, 700 cigarettes
Fatal cancer risk 1:500 (1yo), 1:1,000 (young adult), 1:10,000 (elderly)
Pan-scan is 1600 CXRs, as little as 1:500 fatal cancer risk
Cancer screening low risk populations
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Prostate - PSA
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lifetime risk of dying from Ca prostate is 3%. Unchanged since the 70s.
diagnosis has quadrupled since PSA screening
40% of 40-50yo, 80% of >70yo have prostate cancer
risk of radical prostatectomy: impotence (50%) incontinence (33%)
1000 screened: 1 man helped, 30-100 harmed by over-diagnosis
Breast - screening mammography
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helps some but hurts more, esp low risk under 60s
Screen 40-50yo - 1/3 false +ve & will miss 1/4 cancers destined to
appear in the next year
Cochrane: Screen 2000 women for 10 years and you will prevent 1
death. At the cost of 10 healthy women over-diagnosed(6 lumpectomies
and 4 mastectomies) and 200 women worried about test abnormalities
5 determinants of health and longevity
1. Genetics
2. Behaviour (alcohol, smoking, diet, exercise)
3. Social circumstances
4. Environmental exposure
5. Healthcare is the least important
So don’t just do something, stand there!
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STOP doing/giving/performing UNNECESSARY
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IV lines if they don’t need IV meds/fluids
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blood tests on every ED attendance
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low specificity blood tests on low risk populations
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CT scans in trauma / uncomplicated ureteric colic
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Antibiotics in viral URIs, sinusitis
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Antibiotics for uncomplicated wounds
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Microbiological tests - urine/blood cultures, wound swabs
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CRaP as a measure of “unwellness”
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Augmentin is not the only antibiotic
Choose wisely in Emergency Medicine
Use caution/avoid:
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CT/KUB for uncomplicated ureteric colic
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Cx spine imaging outside validated decision instrument
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CT brain in trauma outside a validated D.I.
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CXR in ACS patients unless other pathology suspected
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Routine blood cultures
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Coag studies without indication
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CRP outside occult inflammatory and infective conditions
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Imaging in low back pain without high risk features
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Antibiotics for asymptomatic bacteria
Choose wisely in Surgery
Examples of low value care:
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Spinal fusion for degenerative conditions in older people
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Epidural steroid for back pain/sciatica
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Spinal cord stimulators for chronic back pain
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Surgery for lateral epicondylitis
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Knee arthroscopy for uncomplicated OA
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Stem cell injections for OA
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Tympanostomy tubes for chronic otitis media
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Appendicectomy in uncomplicated appendicitis
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PCI for stable non-critical coronary disease
5 questions patients should ask their doctor
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Do I really need this test / procedure?
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What are the risks of having / not having the test / procedure?
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Are there simpler / safer options?
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What happens if I do not do anything?
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What are the costs?
Challenges
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Establishing change in the face of entrenched dogma
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Resistance by those with conflicts of interest or vested interests
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Group-think and vested interests in special societies
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“Doctors often unknowingly rely on biased evidence, what others
have taught them, what is common practice, what appears to work,
and on studies that fit with their beliefs"
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“The fear of having someone harmed from a missed opportunity is a
strong and emotive driver of over-treatment. So is the belief that
non-operative management equates to neglect or no treatment”
How to make it happen
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Win the public hearts and minds - media, social/other
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Local campaigns - “one less prick”
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The entire medical profession must work together
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Specialists must educate their referral base esp GPs
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Educate across the medical spectrum from medical students up.
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Sell it as a flagship for high value care and a better service
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Try to shift from “don’t” and “stop” to a more positive message
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Deprescriptions
Practice-changing reading
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Over-diagnosed - H Gilbert Welch
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Bad Science and Bad Pharma - Ben Goldacre
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Anatomy of an Epidemic - Robert Whittaker
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Hippocrates Shadow - David Newman www.thennt.com
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Surgery, the Ultimate Placebo - Ian Harris
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Being Mortal and The Checklist Manifesto - Atul Gawande
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Others
• Blink and Outliers - Malcolm Gladwell
• Thinking, fast and slow - Daniel Kahneman
And finally
Cost of tests is not just $$
Our ability to help the sick/injured is soon to be
outstripped by our propensity to harm the healthy.
Another ‘OD’ patient (vomit)
Don’t just do something, stand there!
We can ‘protect’ our patients from other specialists
Step away from the: IV trolley, CT request pad
EM must own low risk illness/injury