The question of too much medicine
Some of our long-standing site users will be aware of the collaboration between MAGIC and our authoring team, aiming to promote and facilitate good conversations between patients and their clinicians.
There are many decision aids available on this site which provide necessary information to help decide the best course of action for that individual patient; 'No decision about me, without me.'
Across the UK we are becoming more aware of the overuse of medical intervention. This can vary across the country. For example, the prescribing of antibiotics can vary by as much as two and a half times between one part of the country and another.
Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses. A study last year found that 82% of doctors said they had prescribed or carried out a treatment which they knew to be unnecessary.
The problem for patients is that most interventions have side effects and some may even cause harm. Choosing Wisely was created to challenge the idea that more is better - just because we can, doesn't always mean we should. The Choosing Wisely principles encourage patients get the best from conversations with their doctors and nurses by asking five questions.
• Do I really need this test, treatment or procedure?
• What are the risks or downsides?
• What are the possible side effects?
• Are there simpler, safer options?
• What will happen if I do nothing?
The Royal Colleges in the UK were asked to identify five treatments or procedures commonly used in their field where the appropriateness of their use should be discussed carefully with patients before being carried out. The following seem particularly relevant to primary care:
1. When patients are particularly frail or in their last year of life, unless the patient has a clear preference, discuss decreasing the number of medicines to only those used for control of symptoms.
2. Consider dementia when individual patients are seen, rather than routinely screening whole groups of patients.
3. If drug treatment is being considered to prevent heart disease, stroke or osteoporosis in previously well people, ensure that this decision is shared with the individual concerned.
4. Only consider blood pressure treatment with medication when the BP is consistently above 140-159/90-99 mmHg in people with additional risk factors.
5. If you suspect that a woman has polycystic ovaries, check free androgen index or LH: FSH ratio before considering further imaging.
6. If an individual takes a statin at the recommended dose, there is no need to routinely check cholesterol levels unless there is evidence of pre-existing problems.
7. If a woman has abnormal vaginal discharge that is likely to be caused by thrush or bacterial vaginosis and she is at low risk of having a sexually transmitted infection, a vaginal swab is not usually necessary.
8. A woman who may have recurrent thrush should have an examination of the perineal skin to exclude other conditions e.g. lack of oestrogen, allergies or other skin conditions rather than routinely giving further anti-fungal treatment.
9. If a woman is over the age of 45 years with typical symptoms of menopause, blood tests to check hormone levels are not usually necessary.
10. A simple ovarian cyst less than 5cm in diameter in a pre-menopausal woman does not need to be followed up; nor is there any need for a blood test to check levels of the protein CA-125.
11. Aspirin, heparin or progesterone should not be used in a bid to maintain a pregnancy in a woman who has had unexplained and/or recurrent miscarriages.
12. Chemotherapy that is unlikely to be beneficial and may cause harm should have minimal use in advanced cancer.
13. Children with small unilateral wrist fractures do not usually need a plaster cast. They can be treated with a removable splint and written information. They do not need follow up in fracture clinic as they will get better just as quickly without this. Also small fractures of the base of the fifth metatarsal, do not usually need to be put into a plaster cast as they will heal just as quickly in a removable boot.
14. In cases of a minor head injury, imaging is not likely to be useful.
15. Back pain which is uncomplicated and that is not associated with 'red flags' or radiculopathy usually does not require imaging.
16. For children with chronic constipation changes to diet and lifestyle should be considered first to relieve the symptoms. If this is ineffective, macrogols should be considered rather than lactulose.
17. Bronchodilators should not be used in the treatment of mild or moderate presentations of acute bronchiolitis in children without any underlying conditions.
For further information see the Choosing Wisely site.