Basics of medical decisions by layman and physicians, drivers of overuse in medicine, risk competence of medical doctors, lack of national choosing wisely lists

1. Dr. med. Patrick Schur, EMBA SCM, Member of FMH
Spitalfacharzt
Bild durch Klicken auf Symbol hinzufügen
IMPACT OF OVERUSE
AND RISK INTELLIGENCE

2. MEDICAL MAXIMALISME
Patients strongly believe that more
testing and more treatment lead to
better outcomes and that newer
treatments are more effective.
[Carman KI, Maurer M et al. Evidence That Consumers Are Skeptical About Evidence-Based Health Care. Health
Affairs 2010; 29:1-7]

5. «Eine 50-jährige Frau, keine Symptome, nahm
im Vorfeld der Hospitalisation an einem
Mammographie-Screening teil. Das Ergebnis
war positiv, sie sei erschrocken und möchte
von mir wissen, ob sie mit Sicherheit
Brustkrebs hat oder wie gross die
Wahrscheinlichkeit ist.
Abgesehen von den Screening-Ergebnissen
wusste ich nichts über diese Frau.»
«MUSS ICH STERBEN HERR DOKTOR?»

6. Wie gross ist die Wahrscheinlichkeit, dass eine
Frau an Brustkrebs erkrankt ist, wenn sie ein
positives Ergebnis beim Mammographie-
Screening hat?
Die Prävalenz/natürliche
Häufigkeit (9, 1, 89, 901)
entscheidet mit!
[Harding Center for Risk Literacy (https://www.harding-center. mpg.de/de)]

7. FAKTENBOX MX SCREENING
FAKTENBOX
100 Frauen werden
im Glauben eines
Mamma-Ca
gelassen
5 Frauen erhalten
dadurch eine
unnötige Operation
Gesamtsterblichkeit in
beiden Gruppen gleich
Eine Frau von 1000 kann
dank Screening vom Brust-
krebstod gerettet werden.
Das Brustkrebs-Screening wird fälschlicherweise von der Krebsliga Schweiz weiter empfohlen und mit der irreführenden
5-jährigen Überlebensrate von 80% beworben [10]. Die Sterberate fehlt in den wichtigsten Publikationen der Krebsliga.

8. CONCLUSION: FACTBOX, MX SCREENING
Most people – including doctors – have distorted conceptions
about the effectiveness of early diagnosis.
Risk competence of doctors are key, but is missing. They aren‘t
supported by technology. Risk evaluation is not timely available in
the complexity of each individual case.
Factboxes should demonstrate the real proportions, but aren‘t
well established. Always consider the absolute risk reduction of
an action!
Perform socratical silence than treat wrong emotions?

9. DEFINITION OF OVERUSE:
„the supply of circumscribed medical
diagnostic and treatment without benefit or a
mismatch of its risks to the potential benefit“

10. “THE FORMULA“ OF OVERUSE
=
4° prevention
Over examination
Over diagnostic
Over treatment
Over administrationX (bullwhip)
Quality of medical indications
Worries, Stress
Risks
Benefit
Useful diagnosis*
Useful therapy**
Health
Patients perspective Professionals perspective
* with symptoms or symptoms in the future
** with reduction of the absolute mortality

11. 4° PREVENTION
„Ich fürchte mich davor, einer Frau eine
Mammographie nicht zu empfehlen, die
vielleicht später mit Brustkrebs
wiederkommt und mich fragt, warum ich
keines habe machen lassen.
Deshalb empfehle ich das Screening,
obwohl ich persönlich der Ueberzeugung
bin, dass es nicht empfohlen werden
sollte.“ (Aussage einer Gynäkologin)

12. DILEMMA OF ACTION
Doctor‘s Action No Doctor‘s Action
No
Disease
„my doctor doesn‘t
act/did not act“
Useful
Less is more, „red
pills“, Value of doing
nothing
Disease
Useful TTT „Medical error“ or
undetected frist
symptoms.
Nobody knows about the
patient‘s disease with
relevant absolute
morbidity
TTT without change
in absolute morbidity
TTT without
symptoms reduction

13. DRIVERS OF OVERUSE
Patients perspective Professionals perspective
[Welch GH, Schwartz LM, Woloshin S. Die Diagnose Falle. München: Riva; 2013.]
Nature of
Medicine as
an inverse
business
No shared
and
documented
decision
making
Lack of
integrated
Information
exchange /
support at
time
Defensive
medicine
Lack of
workflow
coordination
Lack of com-
munication
skills (risk
and
statistics)
Lack of
evidence
Financial
interests
"hidden
agendas"
Lack of
frontline-
adopted and
lined-up and
legale
reliable
standard
Higher
test
sensitivity
Lower cut-
offs
"Diagnose
mongering"
Lack of
knowledge
about
overuse
Lack of
perception of
evident
information at
time (medical
"boulevard"
evidence)
Lack of
data
ownership
"Hidden
agendas"
Consumer-
isme
Wrong
and
changing
expec-
tations
Lack of
internet
data
security
Overuse
without
sanctions
Lack of
decision
comparison
to trusted
networks

14. SOCIAL TRENDS
Self awareness;
“Quantified Self”;
Agile front-people
driven standards
„corpus
hippocraticum“ Medical Autocracy
Informed Holocracy
[Pschyrembel Klinisches Wörterbuch. 255. Auflage. de Gruyter, Berlin/New York 1986,
ISBN 3-11-007916-X. S. 695 f. s. v. Hippokratischer Eid.]

15. HOW TO CHANGE SPECIALISTS
DECISIONS ?
We expect medical innovations from better
technologies and not from better doctors, who
understands the technologies.
Specialists decisions are experience/eminence
based and not only evidence based, aren‘t timely,
aren‘t workflow supported and not instantly shared.
System responsibles have different perspectives
than front-line people. There‘s a gap in
understanding and in system adoptions, especially
in matrix organizations.

16. [Hofmann B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol. 2014;29(9):599–604.]
EVIDENCE ABOUT OVERUSE
Overuse hurts the principle of ethics and efficiency
Evidence through retrospective population studies
.. but big effort needed and high complexity !!!
Some medical reviews in the USA
Some studies in cardiac interventions and the use
of antibiotics in CH
[Kale MS et al.Trends in the over- use of amulatory health care services in the U.S. JAMA Intern Med. 2013;173(2):142–48.]
[Korenstein D et al. Overuse of health care services in the US: an understudied problem. Arch Intern Med. 2012;172(2):171–8.]
[Institute of medicine. Crossing the quality chasm: A new health system for the 21st century – Brief report. 2001. Available from:
http://www.nap.edu/books/0309072808/html/]

17. LIMITATIONS → SOLVING
1. supply research needed → SNF74
2. choosing-wisely list (CWL), „should not“-
guidelines→ Elaboration for each speciality (.. and
revisions .. )
3. pretest vs posttest P, NNT, Quality of Life,
absolute risk reduction → Again, relevant statistics!
4. patient information → Elaboration of fact boxes
5. risk intelligence → Action/communication training
„how to learn and do nothing“

20. CHALLENGE
•MAXIMIZE IMPACT
by focusing on fewer
items (5 to 10 items)
•IMPACT could be based on:
Frequency performed actions
Cost savings by avoiding that activity
Potential harm to patients from activity
Level of evidence
[Smarter Medicine Liste «Top 5», www.smartermedicine.ch, as of: May 2014.]
[Gerber M et al. „Choosing Wisely“- für weniger unnötige Leistungen. SAEZ 2017;98(5):140–143.]

21. TRANSPARENT WORKUP
CHOOSING WISELY LIST
Expert task force
Discharge
of the board
[Gerber M et al. „Choosing Wisely“- für weniger unnötige Leistungen. SAEZ 2017;98(5):140–143.]
[Creating a List of Low-Value Health Care. Activities in Swiss Primary Care. JAMA Internal Medicine
2015; 175(4): 640-642]
Formal
consensus
workup

22. Five Physical Therapy Treatments
You Probably Don‘t Need (1)

23. Five Physical Therapy Treatments
You Probably Don‘t Need (1)
1.
Ulus Y, Tander B, Akyol Y. Therapeutic ultrasound versus sham ultrasound for the management of patients
with knee osteoarthritis: a randomized double-blind controlled clinical study. Int J Rheum Dis. 2012
Apr;15(2):197-206.
Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of
pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study.
Phys Ther. 2009 May;89(5):419-29.
Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys Ther. 2001
Jul;81(7):1339-50.
Graham N, Gross A, Goldsmith C, Michlovitz S. Heat and cold for neck pain: A systematic review.
Physiother Can. 2009;61:73-73.
French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004750.
Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM. Subacromial
impingement syndrome–effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014
Aug;48(16):1202-8.
Davis AM, MacKay C. Osteoarthritis year in review: outcome of rehabilitation. Osteoarthritis Cartilage.
2013 Oct;21(10):1414-24. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder
pain. Cochrane Database Syst Rev. 2003;(2) CD004258.

24. Five Physical Therapy Treatments
You Probably Don‘t Need (1)
2.
Silva NL, Oliveira RB, Fleck SJ, Leon AC, Farinatti P. Influence of strength training variables on strength
gains in adults over 55 years old: A meta-analysis of dose-response relationships. J Sci Med Sport.
2014;17(3):337–44.
Raymond MJ, Bramley-Tzerefos RE, Jeffs KJ, Winter A, Holland AE. Systematic review of high-intensity
progressive resistance strength training of the lower limb compared with other intensities of strength
training in older adults. Arch Phys Med Rehabil. 2013;94(8):1458–72.
Valenzuela T. Efficacy of progressive resistance training interventions in ol der adults in nursing homes: a
systematic review. J Am Med Dir Assoc. 2012;13(5):418–28.
Mayer F, Scharhag-Rosenberger F, Carlsohn A, Cassel M, Muller S, Scharhag J . The intensity and effects
of strength training in the elderly . Dtsch Arztebl Int. 2011;108(21):359–64.
Nicola F, Catherine S. Dose-response relationship of resistance training in older adults: a meta-analysis.
Br J Sports Med. 2011;45(3):233–4.

25. Five Physical Therapy Treatments
You Probably Don‘t Need (2)
Same
problem
in CH ?
→ compression stocking

26. Five Physical Therapy Treatments
You Probably Don‘t Need (2)
3.
Aissaoui N, Martins E, Mouly S, Weber S, Meune C. A meta-analysis of bed rest versus early ambulation
in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009;137(1):37–
41.
Anderson CM, Overend TJ, Godwin J, Sealy C, Sunderji A. Ambulation after deep vein thrombosis: a
systematic review. Physiother Can. 2009;61(3):133–40.
Gay V, Hamilton R, Heiskell S, Sparks AM. Influence of bedrest or ambulation in the clinical treatment of
acute deep vein thrombosis on patient outcomes: a review and synthesis of the literature. Medsurg Nurs.
2009;18(5):293–99.
Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic
review. Thromb Res. 2008;122(6):763–73.

27. Five Physical Therapy Treatments
You Probably Don‘t Need (2)
5.
Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol.
Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 88
p.
Association for the Advancement of Wound Care (AAWC) venous ulcer guideline. Malvern (PA):
Association for the Advancement of Wound Care (AAWC); 2010 Dec. 7 p.
Water use in hydrotherapy tanks [Internet]. Atlanta (GA): Centers for Disease Control and Prevention.
2009 Aug 10 [cited 2014 Apr 23]. Available from:
http://www.cdc.gov/healthywater/other/medical/hydrotherapy.html.
Berrouane YF, McNutt LA, Buschelman BJ. Outbreak of severe pseudomonas aeruginosa infections
caused by a contaminated drain in a whirlpool bathtub. Clin Infect Dis. 2000;31(6):1331–7.
McCulloch J, Boyd VB. The effects of whirlpool and the dependent position o n lower extremity volume. J
Orthop Sports Phys Ther. 1992;16(4):169–73.

28. Five Physical Therapy Treatments
You Probably Don‘t Need (3)
.. we do ½h
twice a day
…
Avoiding
Clabling …
Physio-
therapy is
essential!
I
Same
problem
in CH ?

29. Five Physical Therapy Treatments
You Probably Don‘t Need (3)
4.
Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L, Pelland L, Noel MJ, Davis J, Drouin H.
Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. J Rheumatol.
2004;31(11):2251–64.
Grella RJ. Continuous passive motion following total knee arthroplasty: a useful adjunct to early
mobilisation? Phys Ther Rev. 2008;13(4):269–79.
Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in
people with arthritis. Cochrane Database Syst Rev. 2014;2:CD004260.
van Dijk H, Elvers J, Oostendorp R. Effect of continuous passive motion after total knee arthroplasty: a
systematic review. Physiother Singapore. 2007;10(4):9–19.
Viswanathan P,Kidd M. Effect of continuous passive motion following total kne e arthroplasty on knee
range of motion and function: a systemat ic review. NZ J Physiother. 2010;38(1):14–22.

30. Five Things Physicians and Patients
Should Question (1)
Same
problem
in CH ?

31. Five Things Physicians and Patients
Should Question (2)
Same
problem
in CH ?

32. DRAFT: CHOOSING WISELY RKB AR
..External emergency call through doctors only,
administrative check of destination
..External examinations after approval of
responsible supervisor
..Replace opiace/BZD as soon as possible
..From the beginning antibiotic therapy limited in
time
..Ultrasound instead of repetitive laboratories
..From the beginning goal oriented procedures and
checks (espacially in patch work)
..Support in shared decision making

33. ACKNOWLEDGEMENT