THESIS: Preventing Overdiagnosis, the Quaternary Prevention

Maria Llargués Pou, a soon-to-be Family Physician in Barcelona, recently shared with me her Bachelor's Thesis. 

Her work - "Primum non nocere" Preventing Overdiagnosis, the Quaternary Prevention provides a concise introduction to the efforts around the world to prevent overuse of tests, treatments, and disease-labels, as well as the reasons we must address this growing issue.

“Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy ”

Llargués Pou has beautifully laid out an evolution of ideas, from Ivan Illich's idea of Iatrogenesis, to Jamoulle's attempts to thwart iatrogenic harm with a public health model of Quaternary Prevention, and now, contemporary efforts to tackle overdiagnosis, like the Choosing Wisely Campaign and Preventing Overdiagnosis conference. Her paper serves as a great "backgrounder" for those who wish to learn more about the broad themes and history of this movement.

You can view the full text HERE.

No strong proof that flossing your teeth has medical benefit

This is the third in a series of "no evidence" posts I've made recently, with the first two being "No evidence that N95 respirators are better than surgical masks" and "No benefit to locked mental health wards."

Today's serves as another example of where something seemed like a good idea but... "sURpriSe!!!!" maybe it isn't. 

Certainly, the evidence is lacking to support the bullying that goes on in dental chairs around the world.
"Are you flossing?"
"Yes....."
"Are you sure?"
"Uhhh....." *guilty face*

Personally, as a reluctant flosser, and as a person who questioned the risk/benefit return of having wisdom teeth extracted, I feel a little bit vindicated here. I was always curious 1) if I asked the dentist to guess whether I was flossing or not, could they tell? and 2) Does flossing really do anything useful?

I can't lie to my dentist... how could they do their job if I did? So when asked "have you been flossing?" I usually tell them "no" or "yah but just for 2 months" if I had been doing so, in a phase of thinking I should probably try to stick with flossing. 

Last time I was feeling contemplative in between wafts of chemical smells and *wizzzzzzzes* of the drill in the neighbouring stall, I told my dentist and hygenist that if they could show me solid evidence of benefit of flossing, then I would do it. The hygienist listed a bunch of benefits and I went home to check it out. All the PubMedding in the world didn't find anything to back up her statements. Since they couldn't produce a strong reason for me to do it, so I decided to stop.

Flossing is not fun, it creates waste, and I can think of better things to do with 5 minutes a day. In fact, with those 5 minutes today, I can bring you this article in The Journal of Clinical Peridontology, which found:

The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal. All investigated devices for inter-dental self-care seem to support the management of gingivitis, however, to a varying extent.

The paper did find that  inter-dental brushes (IDBs) are effective in removing plaque. These brushes I have tried and they look like little pipe-cleaners that you shove between your teeth. It feels about as good as it sounds!!! Ow.

I may wait for the randomized controlled trial (RCT) proving that those angry little bristles decrease caries (cavities) before attempting their use again, as "plaque removal" is but a surrogate marker for other things.

Further to the lack of advancement of evidence-based practice in dentistry, one periodontist. Dr Ghilzon, when interviewed by the CBC said:

I would say if you know how to floss I would continue just in case it does make a difference

When the CBC talked to Matthew J. Messina, a dentist and spokesman for the U.S. dental association, they pressed him. He acknowledged weak evidence, but he blamed research participants who didn't floss correctly.

It seems Dentistry is eons behing medicine in terms of evidence gathering let alone application. Whether employing patient-blaming, citing anecdotes, or declining to accept the value of evidence, Dentistry is set to follow Medicine in suffering the same "just in case" approach that dooms patients to overtesting and overtreating and promotes ignorance of the harms of intervention.  

See the original CBC article here.

No evidence that N95 respirators are better than surgical masks

From NinjaCat14 on Deviant Art
I can't make this stuff up!

Specialized technologies are always sexier than their basic alternatives.

We often think that new and complicated is better. Or that if something is more expensive if must work better, right? 

One small trial found that a more expensive placebo was much more effective than the cheap one in Parkinson's patients. There is a lot of interesting research around how cost influences thinking and choice, and much of it is applied by manufacturers to influence their markets (see for example: Relative thinking in consumer choice between differentiated goods and services and its implications for business strategy).

Sometimes we think again about something that is not new, but an existing technology or process that we just use by habit, having assumed for years that it was better than the alternatives. Rarely are these things scrutinized, but sometimes when they are, we find out we are  "all wrong." For example, we have long assumed that acetaminophen is helpful for lower back pain but a meta-analysis in the BMJ in March 2015 found this is not the case.

In a recent Canadian Medical Association Journal (CMAJ) article, Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis, we learned that there really is not a lot of clinical research that supports the effectiveness of N95 masks. In the lab, yes, surrogate markers suggest the N95 masks could be "better" than normal surgical masks, but the data in practice is so lacking. 

Smith et al. concluded that "Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings."

Of course 'insufficient data' doesn't mean we should abandon these masks. While I will still wear N95s for seeing TB patients and for performing high risk interventions on patients with influenza like illness, I now begin to wonder if this is really necessary.

There are so many 'fancy' technologies that we have discovered are no better than the old ones, and our knowledge of the waste, cost, and sometimes harms associated with them makes it hard to  not carefully scrutinize every 'new alternative' and 'innovation.' 

As I head to Toronto for a meeting of the CMA's Joule Innovation Council this week, I must laugh a bit. I imagine my experience in critical review of medical literature and knowledge of the harms from overtesting/treating/diagnosis, will make me one of the toughest judges of our colleagues' submissions! We are reviewing grant proposals for development of innovations from Canadian physicians.

I hope that with this privilege, I can be both enthusiastic and measured in my assessments, though I won't be surprised if I'm one of the more, uh 'fiery,' of the dragons in the den. With the collective wisdom of the group, I'm certain we will support some elegant, thoughtful, and effective innovations to make a positive difference for patients and health care systems.

Doctors' grade: C- on #ChoosingWisely Test Your Knowledge Questions in CMAJ

Fascinating results emerge from a small online poll of Canadian Medical Association Journal (CMAJ) readers. Web polls on the CMAJ site were done over the span of 7 months and the following 12 True or False questions were asked.

Although not scientific, the results tell us that (at least mildly-) engaged physicians (those going to the CMAJ website) like to provide a lot of unnecessary and harmful care, particularly in the area of diagnostic imaging.

Not only do we need more research on why physicians think this way, we also need research on what methods are effective at changing behaviours. We don't know yet if Choosing Wisely-type outreach to patients and providers can improve practice. We think and hope so . . .

See the Choosing Wisely Canada update for more.

EDIT:

*NB: Dr S.P. Landry has a keen eye and noticed an error; for the item pertaining to "All children with head trauma require imaging to rule our fracture and brain injuries" the answer should be FALSE. So, the correct response rate would be 70% on that question, making the overall score of respondents a little less terrible, but still remarkably bad ;)

Other Blogs: Less Is More | An index of evidence-based, “less-medical” patient care

More "Less is More"!

Dr Bill Cayley Jr has started a Wordpress Blog, "Less is More EBM" to review studies that explore situations in which less involved/invasive/expensive/difficult/novel/etc. care is actually best for patients.

He writes, "This index is currently a personal (and extremely part-time!) project aiming to catalog literature documenting when “less is more” in a searchable and accessible format." It has just started, but there are already insights on papers about overuse of arthroscopy, the best treatment for paediatric upper respiratory infection, and creative solutions for low resource areas (eg. mosquito nets instead of mesh for hernia repair).

It's great to see interest booming. More people are writing books and blogs, talking at conferences, changing the care they deliver, and asking questions of their health care provider. The movement – still known by many names, a few of which are highlighted in the glossary – is growing!

If you are particularly interested in blogs, look at the left sidebar column, and under 'Similar Blogs' you'll find others writing about similar issues as you'll find on this site. Check 'em out!

Choosing surgery wisely: the importance of evidence-based practice

* RESEARCH FIRST LOOK *

Very little research has been done so far in the area of appropriateness in health care, so it is is always a delight to see what is being worked on.

You may remember Roland Grad, a family physician and research at the University of McGill, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign.

Two ambitious McGill medical students, Nicholas Meti and Mathieu Rousseau, worked with Dr Grad to extend that work and look at InfoPOEMs that dealt specifically with surgical interventions which are considered unnecessary or harmful to patients.

Many agree that there's room for the Choosing Wisely campaign to improve; this research presents a potentially fruitful way to do so, particularly for the orthopaedics recommendations which have been heavily criticized to date.

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Choosing surgery wisely: the importance of evidence-based practice

Meti, N., Rousseau, M., Grad, R. Medicine, McGill University, Montreal, Canada.

An emerging trend among physician organizations is to attempt to control or reduce the rate of unnecessary medical tests and treatments. Until recently, the principle manner to release updated recommendations for practice was through meetings where experts discussed which tests or treatments needed to be questioned.  

We developed a novel means of analyzing nascent research articles for their applicability towards improving the “Choosing Wisely” topic selection process [1]. This method is based on analyzing the ratings of daily POEMs, collected from physician members of the CMA. POEMs are tailored synopses of primary research or systematic reviews, selected by searching over 100 journals. POEMs are delivered to over 20,000 members of the Canadian Medical Association (CMA) by email on weekdays.

At the 2015 ‘Preventing Overdiagnosis’ conference, one of us (RG) will report on the top POEMs of 2014, as rated by CMA members with respect to their potential to help them to ‘avoid an unnecessary diagnostic test or treatment’ [1]. Of the topics addressed by these top 20 POEMs of 2014, only 2 were discussed in the Choosing Wisely master list of recommendations. Of the remaining 18 topics, three were related to surgical interventions; we highlight their important findings.

In a study published in The Bone and Joint Journal, Kukkonen et al. used the Constant Shoulder Score to show that among patients with symptomatic non-traumatic supraspinatus tears, physiotherapy alone is as effective as physiotherapy combined with acromioplasty after 1-year follow up [2].

In a study published in the New England Journal of Medicine, Sihvoven et al. investigated whether arthroscopic surgery would improve outcomes for select patients with a degenerative tear of the medial meniscus. The researchers conducted a multicenter, randomized, double-blind, sham-controlled trial involving patients without knee osteoarthritis, but with symptoms of a degenerative medial meniscus tear. Surgery was found to be ineffective for non-traumatic partial medial meniscus tears [3].

A study published in JAMA by Primrose et al. [4] questioned the routine practice of intensive follow-up after surgery for colorectal cancer, as there existed no evidence to support this common practice. In a randomized controlled trial, 1,202 participants were assigned to 4 groups: CEA only, CT only, CEA+CT, or minimum follow-up. Their results demonstrated that among patients who had undergone curative surgery for primary colorectal cancer: 1) intensive imaging or CEA screening each provided an increased rate of surgical treatment of recurrence with curative intent, compared with minimal follow-up; 2) there was no advantage in combining CEA and CT; and 3) there was no statistically significant survival advantage to any strategy.

One concern about the development of top five lists in Choosing Wisely is the potential for individual specialties to choose the low hanging fruit. For example, the American Academy of Orthopaedic Surgeons included no major surgical procedures in their top 5 list, despite evidence of wide variation in elective knee replacement and arthroscopy rates [5]. This observation is not meant to be a criticism of orthopedic surgeons per se, as many surgeons are strong advocates for their patients (see http://www.thepatientfirst.org). [Less is More readers will remember one of the founders, Dr James Rickert, from What Can Patients Do in the Face of Physician Conflict of Interest]

Our point is to drive home the underlying philosophy of the “Choosing Wisely” campaign: ‘routine’ testing or treatment without evidence-based support can be found insidiously entrenched in all disciplines.

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References

1. Grad RM, Pluye P, Shulha M, Tang DL. POEMs Reveal Candidate Clinical Topics for the Choosing Wisely Campaign. Preventing Overdiagnosis Conference, Bethesda, MD, September 2015.

2. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J 2014; 96(1):75-81.  
http://www.ncbi.nlm.nih.gov/pubmed/24395315

3. Sihvonen R, Paavola M, Malmivaara A, et al., for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369(26):2515-2524.    http://www.nejm.org/doi/full/10.1056/NEJMoa1305189

4. Primrose JN, Perera R, Gray A, et al., for the FACS Trial Investigators. Effect of 3 to 5 years of scheduled CEA and CT follow-up to detect recurrence of colorectal cancer. The FACS randomized clinical trial. JAMA 2014; 311(3): 263-270. 
http://www.ncbi.nlm.nih.gov/pubmed/24430319

5. Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely—the politics and economics of labeling low-value service. N Engl J Med 2014; 370:589-92. 
http://www.nejm.org/doi/full/10.1056/NEJMp1314965

BMJ Blogs: Six proposals for EBM’s future

Dr Paul Glasziou is a Professor of Evidence-Based Medicine at Bond University in Australia. He speaks and writes mainly about the translation of health research into clinical practice.

His latest contribution to the BMJ Blog is a look at the future of evidence-based medicine (EBM). As its era fades into another, it becomes apparent that there is still a huge gap between what research tells us and what doctors and patients wind up doing.

Sometimes the known evidence is biased, of poor quality, or doesn't actually have any relevance for our patient. Sometimes, we have strong evidence about what is clinically 'correct' but we have forgotten to remember that each patient is an individual, with unique goals and life circumstances. Sometimes, we get so caught up in chasing the potential benefits of something that we fail to realize it could be causing more harm than good.

Read Dr Glaszious' Six Proposals for EBM's future, as he tackles these tough issues and helps to guide us back to a place where research improves care.

The one chart you need to (begin to) understand any health study

Jullia Belluz, common-sense and evidence-oriented journalist (known to me from her great "Science-ish" Maclean's column) and Trudeau Scholar and Assistant Professor of Law at the University of Ottawa, Steven Hoffman, team up in their Burden of Proof column for Vox.

This week, in "The one chart you need to understand any health study" they help readers with a simple approach to understanding how to evaluate levels of evidence. Not all research is created equally:

This is a chart from the article, modified slightly. It has been beautifully "enhanced" with the added last line by Peter Cook, @DoodlePeter. I couldn't resist sharing Peter's version!

I think the chart it is a good start, and I wish it were as simple as this. Some sneaky (or inept) researchers are good at making trials look randomized, blinded, and so on but the controls, conflicts of interest, low study numbers, etc. mean that the data they gather is not very useful at all. Sometimes, the way the papers are written, it's easy to think of the conclusion as groundbreaking and accurate, but digging deeper into the methods it becomes clear that the authors did a little.... 'creative interpretation'.

Even the highest form of evidence comes in different flavours:

Not all systematic reviews are created equally, either.

And while some evidence is stronger than other evidence, it doesn't necessarily mean anything when it comes to applying it to you, the individual. Fortunately, Ms Belluz and Mr Hoffman get it.

Even with the best available evidence from around the world at our disposal, we have to analyze it and apply it to our particular circumstances. A personal experience with the success or failure of a drug, like an allergic reaction, is more informative for you than the most rigorous study on the drug ever could be. 

It can be challenging to spot issues with quality amongst the jargon and statistics. It is so refreshing to see journalists like Julia Belluz who get this and who are raising the bar for colleagues to be responsible with their science reporting.

Follow @JuliaOfToronto and @SHoffmania on Twitter

CHANGE Alberta: Reversing Metabolic Syndrome with Exercise and Diet

The whole point of a "Less is More" approach to Medicine is to focus on things that really help people live well. If we take resources from unnecessary tests and treatments, we could instead invest in social determinants of health, preventative health, and the tests and treatments that actually make a difference to the quality (and quantity) of people's lives.

It's no secret that an active lifestyle and a reasonable diet correlate with better physical and mental health. While unfortunately the studies have not been yet done to show that exercise prevents cardiovascular events in people with increased cardiovascular risk, we do know that generally, people who exercise can gain up to 4.5 years of life compared with sedentary counterparts. However, it is very hard for family doctors, and even NPs who may have a bit more time with each patient, to help patients alter their eating and exercise habits in a meaningful and lasting way.

Enter CHANGE Alberta. The Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) Alberta project seeks to find a way to reverse metabolic syndrome by supporting patients with nutrition and activity plans. Explore the website to learn more about the team-based approach, involving dieticians and kinesiologists, that they employed in primary health care settings.

I met Dr. Doug Klein (@DrDougKlein) at the Family Medicine Forum in Quebec in November, where he was sharing their promising results; with 302 patients enrolled, at one year, 28% had reversal of Metabolic Syndrome and overall 52.4% had reversal of at least one feature of Metabolic Syndrome.

Is this something you could integrate into your primary health clinic?