Overtreatment

Question 1

What is overtreatment

Answer 1

• Overtreatment refers to unnecessary medical interventions
  
  • Unnecessary treatment of a self-limiting condition
  • Unnecessary extensive treatment for a condition which requires only limited treatment
• Overdiagnosis can lead to overtreatment

Question 2

Examples of overtreatment

Answer 2

• Overuse of antibiotics
• Over-referral of patients for x-rays, MRI scans
• Hospitalisation of patients who could be treated in the community
• Surgery in patients in the final stages of life

Question 3

Incidence and mortality from thyroid cancer in South Korea

Answer 3

Question 4

Is overtreatment a result of the system

Answer 4

Question 5

Why does overtreatment happen- Defensive medicine

Answer 5

• Defensive medicine occurs when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily or solely) to reduce their exposure to malpractice liability. When physicians do extra tests or procedures primarily to reduce malpractice liability, they are practising positive defensive medicine. When they avoid certain patients or procedures, they are practising negative defensive medicine

Question 6

Does the UK system minimise overtreatment

Answer 6

Question 7

Consultant-led Referral to treatment data for England

Answer 7

Question 8

Overtreatment as a result of changes to thresholds for initiating therapy- statins

Answer 8

• NICE guidelines CG67 (May 2008)
  
  • Initiate statin therapy when 10-year risk of developing CVD is 20% or greater
• NICE guideline CG181 (July 2014- to replace CG67)
  
  • Initiate statin therapy when 10-year risk of developing CVD is 10% or greater

Question 9

CVD risk

Answer 9

Question 10

Effect of change in guidance on outcomes

Answer 10

• Changing the guidelines is estimated to make 4.5 million more people suitable for statins, although only half are likely to choose to be prescribed them
• NICE believes the measure will save upto 4,000 lives- as well as preventing 8,000 strokes and 14,000 non-fatal heart attacks- over three years

Question 11

Effect of change in guidance on number of people treated

Answer 11

Question 12

Effect of change in guidance on population level outcomes

Answer 12

• 4000 lives per 2.25 million
  
  • =1.78 lives per 1000
  • NNT= 563
• 8000 strokes per 2.25 million
  
  • =3.56 strokes per 1000
  • NNT= 282
• 14,000 non-fatal heart attacks per 2.25 million
  
  • 6.22 non-fatal heart attacks per 1000
  • NNT= 161

Question 13

Individual-level outcomes : statins in persons at low risk of cardiovascular disease (5 years)

Answer 13

• 0% save from death
• 0.5% prevented from having a MI
• 0.3% prevented from having a stroke
  
  • 0.5% developed diabetes
  • 4.8% experienced muscle damage

Question 14

Does the quality and outcomes framework (QOF) incentivise overtreatment

Answer 14

• Reward and incentive programme for GPs
• Aimed at improving quality in primary care
• Practices receive points for meeting certain indicators
• Points are translated into extra fees (on top of capitation payments)
• 2019/20
  
  • 559 points available in total
  • Practices pain £187.74 for each point they achieved
  • Practice getting all 559= £104,946.66

Question 15

QOF indicators for hypotension

Answer 15

• Establish and maintain a register of patients with established hypertension (6 Points)
• Percentage of patients with hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less (20 points- threshold 45-80%)

Question 16

Overtreatment of mild Stage 1 hypertension

Answer 16

• Systolic pressure of 140-159 mmHg
• 22% of adults worldwide have mild hypertension
• Over 50% of people with mild hypertension are treated with drugs
  
  • Guideline driven
• BUT
  
  • Very little evidence to suggest that drug treatment is effective in reducing mortality or morbidity in mild hypertension

Question 17

Mild hypertension- a scenario

Answer 17

Question 18

Summary of factors influencing overtreatment in the NHS

Answer 18

• Guideline-driven practice
• Incentive payments for doctors
  
  • Practice pharmacists might be incentivised to help GPs meet these targets
• Defensive medicine
• Demand
  
  • System-level
  • Patient-level

Question 19

Consequences of overtreatment for patients

Answer 19

• Patients are put at unnecessary risk
• From adverse drug reactions
  
  • Estimated that 6.5% of all admission to general hospital are related to ADRs
  • Serious falls 40% more likely in over 70s treated with anti-hypertensives vs those not treated
• From unnecessary interventions
  
  • E.g. treatment for breast and prostate cancers that would never prove fatal
• From other phenomena
  
  • E.g. antibiotic resistance owing to overuse

Question 20

Financial consequences of overtreatment

Answer 20

• Taxation-funded model (e.g. NHS)
  
  • Waste of tax-payers money
    
    • Diversion of resources away from areas where it could be used more effectively
    • Reduces levels of service/increased taxes
• Private insurance-funded model (e.g. US)
  
  • Extra resources for providers (e.g. hospitals and doctors)
    
    • Where ‘for profit’ model- leaves system as profit
    • Increased insurance premiums for individuals

Question 21

Health expenditure per capita

Answer 21

Question 22

Combating overtreatment

Answer 22

• Better evidence
• More evidence on the scale and consequences of overtreatment
• More nuanced RCTs
  
  • The hope is that better stratification of people by disease stage, or baseline risk of relevant outcomes, will enable better identification of who will benefit and who will be harmed by an intervention, potentially informing the development of more appropriate diagnostic cut-points and treatment thresholds, ultimately reducing overdiagnosis and overtreatment

Question 23

Combating overtreatment

Answer 23

• System-level change to eliminate vested interests
• Avoidance of conflicts of interests amongst panels who recommend changes to diagnositc/treatment criteria
• Abolition of incentives of dubious value
• Cultural change
  
  • Earlier not always better, treatment not always necessary/desirable

Question 24

Summary

Answer 24

• Overtreatment is a level of treatment over and above that which is necessary
• The causes of overtreatment are multifactorial and include profit motives, supplier-induced demand and defensive medicine
• The consequences of overtreatment include harm to patients either directly (through ADRs for example) or indirectly (through increased insurance/tax payments because of inefficient use of resources
• Overtreatment can be reduced but this is complex and difficult