Misuse and abuse of 5 treatmentsBy Rafael Castillo M.D.
Philippine Daily Inquirer
MANILA, Philippines – Anything good which is wrongly used can lead to an unfavorable outcome. In clinical medicine, good treatments, when misused or inappropriately prescribed, can cause adverse effects and complications on the patients or even produce the opposite of what they were intended for.
Healthcare experts in the United States recently gathered to discuss strategies on how to discourage and prevent the overuse of five medical treatments and procedures. This is not only a waste of precious healthcare resources, but it could frequently lead to more serious complications on the long term for the patient.
These experts stressed that appropriate use will improve quality and safety of patient care, and extend finite healthcare resources.
The Joint Commission and the American Medical Association-convened Physician Consortium for Performance Improvement organized advisory panels and working groups which looked into these different treatment areas that tend to be abused and misused.
After a thorough study and deliberation, they offered approaches to address the following problems: overuse of antibiotics for viral upper respiratory infections (URIs); overtransfusion of blood; tympanostomy tubes to drain middle ear effusion or fluids of brief duration; early-term nonmedically indicated elective delivery of the baby; and elective percutaneous coronary intervention (PCI) or angioplasty for patients with blocked heart arteries.
“Overuse” was defined by the advisory panels as the use of medical interventions or treatments that provide zero or negligible benefit to patients, potentially exposing them to harm. This is believed to be a leading contributor to problems with quality and patient safety, affecting millions of patients, and increasing healthcare costs unnecessarily.
Just so one may have a good picture of the waste in financial resources this problem causes, an estimated $1 billion is misspent annually on unnecessary antibiotics for adults with viral URIs.
Viral infections are generally self-limiting and resolve with just symptomatic treatments for fever, aches and pains and other symptoms. Most coughs are viral in nature, and yet, antibiotics are frequently prescribed when a patient sees a doctor for coughing.
Sometimes though, it’s the patient who asks for an antibiotic prescription, thinking it’s what he or she needs for the URI. Little do they realize they could be slowly developing antibiotic resistance because of the repeated use of antibiotics. When the time comes that they really need antibiotics for a bacterial infection, they are no longer effective because of tolerance or resistance. Stronger or more potent antibiotics are then required.
The five working groups have recommended straightforward strategies “to inspire physician leadership, support a culture of safety and mindfulness, promote further patient education, remove incentives that encourage overuse, encourage further study and spur other professional organizations to collaboratively address overuse.”
Among the recommendations of the panel, as summed up by Elizabeth Eaken Zhani, media relations manager of the Joint Commission, are:
- Antibiotic use for viral upper respiratory infections. Develop clinical definitions for viral and bacterial URIs, align current national guidelines that are contradictory, and initiate a national education campaign on overuse of antibiotics for viral URIs.
- Appropriate blood transfusions. Develop a tool kit of clinical education materials for doctors, expand education on transfusion avoidance and appropriate alternatives to transfusion, and develop a separate informed consent process for transfusion that communicates the risks and benefits.
- Tympanostomy tubes for middle ear effusion of brief duration. Develop performance measures for appropriate use of tympanostomy tubes, determine the frequency with which tympanostomy tubes are performed for inappropriate indications in otherwise healthy children, and focus national research on issues related to tympanostomy tubes, including the role of shared decision making with parents and other caregivers.
- Early-term nonmedically indicated elective delivery. Standardize how gestational or pregnancy age is calculated, make the early elective deliveries indications and exclusion list as comprehensive as possible to improve clinical practice, and educate patients and doctors about the risks of nonmedically indicated early elective deliveries.
- Elective percutaneous coronary intervention. Encourage standardized reporting in the catheterization and interventional procedures, encourage standardized analysis/interpretation of noninvasive testing for ischemia or the lack of oxygen in the heart, focus on informed consent and promote patient knowledge/understanding of the benefits/risks of PCI, and provide public and professional education.
We hope our local medical organizations, in collaboration with the Department of Health or the Philippine Food and Drug Administration, can do a similar initiative here to review common treatments and procedures done in their respective medical specialties which may be subject to misuse or abuse. A greater awareness on these can make a doctor think twice before prescribing such treatment or procedure.
“Overuse is a serious problem that involves many complex decisions between doctors and patients,” said Mark R. Chassin, MD, FACP, MPP, MPH, head of the Joint Commission. “The recommendations from the summit will raise awareness that will help both doctors and patients make better decisions going forward, and ultimately improve quality and patient safety.”
American Medical Association president Ardis D. Hoven, MD, hit the nail on the head when he put it succinctly: “The right patient should get the right treatment at the right time.”