Iona Heath

Long term care for older people.

See also News p 1542 Long term care is a reality for thousands of frail older people, a source of great anxiety for many more and, across the developed world, a political hot potato that shows no sign of cooling. The heat is fuelled by two factors. Firstly, current government policy in many countries is widely perceived to be unjust, with older people themselves paying an ever greater proportion of the costs of health care. Secondly, the rising percentage of older people in the population, while fuelling doom laden economic projections, is inexorably increasing the power of the older vote, producing democratic pressure for change that is gradually intensifying. This weeks changes to the funding of long term care in Scotland will further intensify this pressure (p 1542). Very shortly after winning power in May 1997, the New Labour government in the United Kingdom sought to deal with the problem by appointing a royal commission to examine the options and to recommend how the costs of care should be apportioned between public funds and individuals.1 In June 2000, after delaying a decision for more than a year, the government refused to implement the commissions most important …

Beyond diagnosis: rising to the multimorbidity challenge

Urgently needs radical shifts in research, evidence based guidance, and healthcare

The challenge of overdiagnosis begins with its definition

Overdiagnosis means different things to different people. S M Carter and colleagues argue that we should use a broad term such as too much medicine for advocacy and develop precise, case by case definitions of overdiagnosis for research and clinical purposes

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

Quality in primary health care: a multidimensional approach to complexity

Good care is much more than meeting disease specific targets. Iona Heath and colleagues argue that assessments of quality must take into account all the complexities of primary health care

Measuring performance and missing the point

Targets do not necessarily translate into improvements for service users. Iona Heath, Julia Hippisley-Cox, and Liam Smeeth argue that performance measurement in the UK is shifting focus from what each patient needs and those who need it most

Is clinical prevention better than cure

In wealthy countries, the focus of clinical care is changing from cure to prevention, to anticipate future diseases in currently healthy individuals. We review the challenges that clinicians face, such as: prevention can cause harm; predicting the benefi t of preventive activities for the individual, as opposed to the group, can be diffi cult; prevention is not of equal value to everyone; and prevention is beginning to take priority over treatment. Clinicians need to be vigilant to avoid colluding with those who have vested interests in some preventive activities. Finding the right balance between prevention and treatment is a daily challenge. Many reasons exist for the increased emphasis on prevention, including the identifi cation of risk factors for disease, increased social expectations of a long and healthy life, and collusion of many commercial and professional interests in profi ting from the creation of new markets: the social, professional, and fi nancial rewards for prevention can be considerable. In clinical care, treatments are intended to cure or alleviate symptoms and signs. By contrast, prevention is done to ward off something in the future. Clinical prevention, including immunisation and lifestyle advice, is an important and positive component of almost every clinical visit. However, with increasing responsibility for specifi c populations and recognition of the many diverse infl uences on the occurrence and progression of illness, the concepts underlying prevention have become muddled. For example, is the identifi cation of a risk factor always (or even generally) an indication for preventive activities? Prevention has always had its detractors, but new thinking is needed about the benefi ts and potential harms of prevention in clinical practice. The potential consequences of preventive measures include: possible disruption of cultural and individual capacities to cope with sickness, pain, and death; increased fear and perception of illness where none exists; and clinicians’ frustration over a growing list of requirements that are impossible to accommodate within the clinical visit. Here, we explore several specifi c challenges and suggest possible ways of tackling them. Clinicians all over the world, but particularly in wealthy countries, are our target audience because we argue that many preventive interventions are promoted without suffi cient evidence of their benefi ts, cost-eff ectiveness, and feasibility in routine clinical visits, within which preventive strategies must compete with the management of the problems that patients present. Prevention has an aura of omnipotence and good sense. However, is it always true that prevention is better than cure? Consider the example of hypertension: evidence exists that the benefi ts of screening and treating substantially outweigh the harms; yet treatment can be complex and expensive, making it diffi cult for clinicians to carry out the recommended control strategies. Furthermore, treatment for hypertension almost always heightens anxiety and usually needs many consultations and examinations, and drugs that patients must take for the rest of their lives—a particularly important issue for young adults with mild hypertension, and with no guarantee of individual benefi t. In many ways, the pitfalls of prevention mirror those of clinical care: setting of priorities, gathering and interpreting evidence, weighing benefi ts and costs in the presence of comorbidity, and being aware of the possibility of adverse events. The principle of “fi rst do no harm” is paramount. Prevention needs more careful assessment than does treatment because it is presented as benefi cial to people who are well—indeed, it is typically initiated by the doctor rather than the patient—and yet carries a real risk of causing harm. Therefore, clinicians should give cautious guidance and provide careful ongoing monitoring for psychological and physical sideeff ects. The individual’s current level of health should always be taken into account because clinicians, in their attempt to do everything possible, will initiate multiple preventive, diagnostic, and therapeutic activities, each of which leads to interventions with well documented but poorly recognised ill eff ects. The administration of several interventions and medications, even if each is of high quality, increases the risk of adverse eff ects and drug interactions: hence the potential importance of quaternary prevention—ie, actions taken to identify patients who are at risk of over-medication, to protect them from new medical interventions. Quaternary prevention is particularly relevant in the elderly, whose comorbidity is associated with increased fragility. Clinicians have ethical obligations to protect patients at risk of harm from excessive interventions. Clinical prevention based on the identifi cation of risk factors has stimulated the development of prediction rules that use clinical fi ndings to make a diagnosis or predict an outcome, of which the Framingham coronary heart disease risk function is perhaps the best known. Prediction rules have become popular as aids in planning preventive and curative interventions. However, the widespread application of prediction rules has taken place through prediction rules being equated with decision rules, population risk being translated into individual risk, and rules being applied to populations other than those on whom they were developed (the use of the Framingham risk function being an example). Diseases have been recast on the basis of often arbitrary laboratory Lancet 2008; 372: 1997–99

There is no evidence base for proposed dementia screening

Although we welcome the government’s attention to dementia and its timely diagnosis, we are writing to express concerns about the potential consequences of the recent announcement by the health secretary of a “dementia case finding scheme.” The proposal is that doctors should “proactively” ask patients at risk of dementia—including all those aged 75 or over—about their memory, and offer a screening test.1 2 This proposal has moved beyond the raising of awareness about dementia and amounts to a clear intention to screen a section of the population for the condition, without the articulation of any evidence that it fulfils the established criteria for screening. This could lead to overtreatment, harm to patients, unnecessary expense, and diversion of precious resources away from other services, including support for people who are seeking help for a timely diagnosis of dementia or who have already been given a diagnosis. We argue that before any screening programme is introduced it must be shown that the benefits outweigh any potential harm.3 Screening for dementia must be assessed in the same way as any other screening intervention. We acknowledge the prevailing view that early diagnosis (if an accurate diagnosis were possible) …

The importance of values in evidence-based medicine.

BackgroundEvidence-based medicine (EBM) has always required integration of patient values with ‘best’ clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored.DiscussionIn this paper, we address this gap by demonstrating how a consideration of values can enhance every aspect of EBM, including: prioritizing which tests and treatments to investigate, selecting research designs and methods, assessing effectiveness and efficiency, supporting patient choice and taking account of the limited time and resources available to busy clinicians. Since values are integral to the practice of EBM, it follows that the highest standards of EBM require values to be made explicit, systematically explored, and integrated into decision making.SummaryThrough ‘values based’ approaches, EBM’s connection to the humanitarian principles upon which it was founded will be strengthened.

Tackling NCDs: a different approach is needed.

www.thelancet.com Vol 379 May 19, 2012 1873 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ The view by Jan De Maeseneer and colleagues that the priority in relation to non-communicable diseases (NCDs) is a health-service response is deeply fl awed. Non-governmental organisations have been struggling, in the current debate stimulated by the UN High-Level Meeting on NCDs, to shift the focus to environmental change to reduce exposure to the drivers of risk behaviours that contribute so strongly to NCDs. Do we really want to continue to live in a world where the oversupply and marketing of tobacco, alcohol, unhealthy processed foods, and soft drinks is tolerated simply to allow continuing profi ts for the shareholders of the transnational corporations producing and distributing them, while the taxpayer funds the health services and pharmaceutical response to the ensuing disease and injury?