Monday, 26 June 2017

I do therefore I am or the bias of intervention in medicine

Cristina Roure


This week, thanks to a post of Sergio Minué in the blog "El Gerente de Mediado", I discovered the recent publication of "Ending Medical Reversal" The book refers to situations in which new studies more robust than the pre-existing ones contradict the standards of commonly accepted practices, which have now proved ineffective or even harmful.

Some will recall such vivid examples as the use of protein C activated in sepsis, high dose chemotherapy combined with autotransplant of stem cell in metastatic breast cancer, the aprotinin in cardiac surgery, or hormone replacement therapy in postmenopausal women. All of them were used for years until proven harmful.

I have not been able to read the book yet, but I read a report by the same author; Dr. Vinay Prasad in Mayo Clinical Proceedings exposes his vast research. Over ten years, 363 studies evaluating established practices were published, out of which 146 (40%), between 12 and 19 per year, were revoked (1). The author explains in the following video that such revocations usually occur after the precipitous adoption of new therapies based on incomplete or inadequate studies.



The consequences of aversion to revocation are evident:

a) Patients’ exposure to adverse effects in exchange for a zero benefit
b) Waste of health resources and threat to the system’s sustainability 
c) Patients’ distrust in the system and in the professionals
d) Contamination of the shared clinical decision process.

Therefore, it would be logical to correct quickly and abandon the revoked practices as soon as possible, but this isn’t usually the case, and on average the practice persists for ten years before being abandoned.

Cognitive bias is the tendency to maintain a partial perspective that distorts the perception of what is obvious is called cognitive bias and appears to be prevalent in medical practice.

Intervention Bias  is the unconscious tendency of professionals or the medical community to intervene, either with drugs, diagnostic, tests or with procedures, when non-intervention would be a reasonable alternative or even better. The existence of this intervention bias has been demonstrated in several surveys carried out with professionals who, before two equivalent options, they usually choose the interventionist versus conservative option (2).

The causes that explain these biases are diverse. We are often seduced by elegant and sophisticated rationally impeccable and basic science arguments, with the illusion that they can predict what will happen in practice, and we adhere to it without waiting for the necessary evidence regarding its benefits and the real risks to be generated. Here we can add the confirmation bias, or the unconscious tendency to favour the information that confirms our hypothesis (3). Conflicts of interest, not necessarily economic, don’t help either; these sometimes, intentionally, conceal or delay the publication of the complete results of studies when they are negative (publication bias). Defensive medicine that abuses diagnostic tests while being aware of their futility doesn’t help and neither does the relative incompetence of the medical community for the critical evaluation of evidence or the understanding of risk that explains the tendency of professionals to overestimate the benefits of treatments against risks.

But if faced with the new options we can frequently observe an intervention bias, in contrast, when faced with the revocation of established practices, other biases such as the status quo bias, the anchoring or aversion to loss biases predominate. One example is the persistence of screening programs for some cancers despite accumulated evidence of their ineffectiveness in reducing mortality.

The status quo bias occurs when the individual gives more value to the losses associated with the decision than to the potential gains. I recommend you read Jordi Varela’s post illustrating the bias of the status quo with some examples where, despite having been revoked, the often preventive clinical practice is maintained. This type of bias is reinforced by other biases such as the aversion to loss or anchoring bias or the omission that occurs when faced with two reasonable alternatives; the fear of negative consequences of action is greater than that fear derived from the eventual consequences of the inaction and, therefore, the maintenance of the status quo is strengthened.

We can see that the medical community is enthusiastic about new practices and tends to adopt them quickly, even when they are based on studies with clear limitations, but the same medical community is much more reluctant to abandon them when they are ineffective or harmful, even when faced with clear evidence. Despite the famous “primum non nocere”, if the question is to do or not to do, it’s clear that in medicine, the tendency is toward the first option. 

Bibliopgraphy:

  1. Prasad V et al. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clinical Proceedings 2013;88(8):790-798.
  2. Foy A, Filippone E. The Case for Intervention Bias in the Practice of Medicine.Yale Journal of Biology and Medicine 2013; 86: 271-280.
  3. Schiff G et al. Principles of conservative prescribing. Arch Intern Med 2011; 171(16):1433-1440.

Monday, 19 June 2017

Chronic Complex Patients and the Blue Ocean Strategy








The book "Blue Ocean Strategy" by W. Chan Kim and Renée Mauborgne has been celebrating 10 years, having sold more than three and a half million copies, and now, to celebrate, a revised edition has just been published. The central thesis of the book is that today's markets are characterized by oversupply and therefore, companies must compete fiercely between them and the oceans (It’s a metaphor) are stained red with the blood of the fight. For this reason, the authors propose to companies to go on the search for blue oceans, like Cirque du Soleil or Ikea, where their products or services will be incontestable because people will see them as novel and useful. The strategy of these companies is clear: their contribution must be perceived as a value innovation, and as a consequence would able to open new unexplored markets like oceans that will not go red.

Leaving aside the commercial aspects of the theory, the book left me with the (attractive) vision of a blue ocean that, inevitably, I have contrasted with the difficulties that all health systems have when it comes to implementing convincing programs of patients’ care and I thought that perhaps at this point a blue ocean strategy would be beneficial when aiming to implement new projects that would arise from overcoming current difficulties. I have to admit that applying Chan and Mauborgne's theories to complex chronic patients is a bit far fetched, but I am convinced that there are some strategic methodology proposals that could be of some use.

Monday, 12 June 2017

The diagnostic process and medical errors








The past 15 years, since the publication of "To Err Is Human" report, has seen a great deal of progress in projects that promote patient safety, especially in programs such as increasing hand washing, identifying patients, surgical checklists or changes in nursing care, but on the other hand the diagnostic process continues to be a matter almost exclusive to medical work although it’s known that this is a very sensitive area for the safety of patients. This new report from the National Academy of Medicine (formerly Institute of Medicine), "Improving Diagnosis in Healthcare," is a follow up document to the aforementioned one, specifically focused on diagnostic errors.

The report defines the diagnostic error as the failure to obtain a detailed, timely explanation of a health problem. Experts have also included in the definition the physician’s inability to know how to explain the diagnosis to the patient. According to the report, diagnostic errors would have an incidence on medical consultations of 5%, accounting for 10% of deaths, 6-7% of adverse reactions in hospitals, as well as the leading cause of litigation in the health area (the figures correspond to the US).

Monday, 5 June 2017

Life quantity or more quality?








Ventricular assisting devices, VAD, or LVAD if for the left ventricle (the most common) are implantable instruments that help pump blood in situations where ventricular ejection force is severely compromised. In some cases the implantation of an LVAD facilitates the waiting for a cardiac transplant, but in others it’s adopted as a definitive solution. The price of the device is around $150,000 while the cost per QALY (cost per year of life earned) is between $200,000 and $400,000. The cost-effectiveness studies still don’t line up much, but the range of documented amounts is nowadays far above the $30,000 of Spanish per capita income. Remember that the WHO introduced the criterion of considering if a treatment is cost-effective when it doesn’t exceed three times the per capita income of a country.

Monday, 29 May 2017

Caesarean section as a consumer good








In private medicine in Brazil, the rate of caesarean section has reached 90% of births. In that country, gynaecologists and midwives, if any, have lost the job of helping women to give birth, and some obstetrical clinics only work to schedule and during office hours. Bad research has not helped either. In the year 2000, a team of researchers led by Dr. Mary Hannah revealed that the caesarean section was a safer practice in breech presentations, information that had an almost immediate impact on clinical practice. Four years later it was found that the research had been poorly done and that its conclusions were wrong, but gynaecologists had already lost the skills (not easy) to practice vaginal births for breech babies. The result is that nowadays the breech foetal position is, assumed to be equivalent to caesarean section, despite the lack of evidence that supports the indication.

Monday, 22 May 2017

Beyond the reforms (on the subject of Franco Basaglia)








What can we do when reforms are in short supply? This is a question that many of us ask ourselves when rigidities and bureaucracies show us their sordid face. Without going any further, the integration of services and community work is the only way (I think there are no dissenters in this) to adequately care for complex chronic patients, but when it comes to the truth, it turns out that the levels of care, professionals’ abilities and the fragmentation of medical specialties are a drag on the progress of the necessary reforms.

I’ve pondered on this when I read that The Guardian had just published a book by John Foot, "The man who closed the asylum" that tells the life of Franco Basaglia, a psychiatrist with an exceptional entrepreneurial force. During the war, according to the author, Basaglia was imprisoned as an antifascist and this experience was key to the fact that when he was appointed director of an asylum in the early 1960s, he realized that the psychiatry practiced in that establishment was inspired by and took the shape of prisons.

Monday, 15 May 2017

The controversy of health checks








The National Health Service announces health checks by making use of the mood of the "Full Monty" or "The Calendar Girls." Let yourself be undressed for a good cause - they say - your body deserves it. In Spain, on the other hand, this approach is more typical to the private offer. "The best way to take care of your health is to open your eyes to possible diseases and not hesitate to undergo periodic tests to prevent them," says "10 Minutos" magazine in an article on the subject. Many private centres have "Medical check-ups" and most insurers and clinics offer health check-ups, as can be seen in an announcement from the Quirón Teknon Hospital: "basic preventive check-up: previously € 820 - now € 690; advanced preventive check: was € 1,800 - now € 1,520". The Sanitas proposal that offers the possibility of choosing between "checks: classic, integral and complete" is also interesting just as the National Conference of Marketing and Sales Management of the Health Sector that says "the most demanded from the iGlobalMed platform are the health checks for managers who are going to work abroad". To end this journey through the world of health reviews, see the clip below from the University Hospital of Navarre website: