E-DRUG: The Lancet Right Care series - over- and underuse of medicine worldwide
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{The series was referred to on E-drug on Jan 8. Here is the complete information - It is long! Thanks Andy. BS]
Dear E-druggers
The Lancet Right Care series can be accessed from http://www.thelancet.com/series/right-care.
[Note: some characters have not transferred correctly to the e-drug format. Go to the original documents to see all correctly.]
The editorial takes a firm stance that echoes a point made strongly in the report of the Lancet Commission on Essential Medicine Policies (http://www.thelancet.com/commissions/essential-medicines):
'National policy makers, regulators, and health technology assessment organisations need to work together to negotiate affordable drug prices, and to publicly fund effective health care and interventions. It is unbelievable that the UK still funds homeopathy, on the one hand,13 and has failed to recognise the outrageously inflated price for phenytoin sodium capsules for patients with epilepsy, on the other.14 Professional societies need to work together at a global level to provide strong, unbiased, evidence-based, and relevant treatment guidelines. Global health leaders need to recognise the opportunity to eliminate poor care and provide right care as the answer to truly and sustainably achieve healthy lives and wellbeing for all.'
The series articles are:
Evidence for overuse of medical services around the world - Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou, Iona Heath, Somil Nagpal, Vikas Saini, Divya Srivastava, Kelsey Chalmers, Deborah Korenstein
Evidence for underuse of effective medical services around the world - Paul Glasziou, Sharon Straus, Shannon Brownlee, Lyndal Trevena, Leonila Dans, Gordon Guyatt, Adam G Elshaug, Robert Janett, Vikas Saini
Drivers of poor medical care - Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug, Shannon Brownlee, John P A Ioannidis, Elliott S Fisher
Levers for addressing medical underuse and overuse: achieving high-value health care - Adam G Elshaug, Meredith B Rosenthal, John N Lavis, Shannon Brownlee, Harald Schmidt, Somil Nagpal, Peter Littlejohns, Divya Srivastava, Sean Tunis, Vikas Saini
Here's the evidence for overuse of medicines:
Overuse of medication
One of the best-documented examples of medication overuse in both HICs and LMICs is the inappropriate use of antibiotics, which represents a worldwide problem that has important consequences for antimicrobial resistance. Many studies have addressed inappropriate antibiotic use in patients with upper respiratory viral infections. A 2012 systematic review of overuse in the US health-care system found 59 studies documenting widely variable rates of overuse of antibiotics for upper respiratory infections.4 In Europe, rates of antibiotic prescribing for viral upper respiratory infections are high in Poland, Sweden, and the UK, with half of patients receiving unnecessary antibiotics.98, 99, 100 Additionally, across the continent, studies have documented variable rates of antibiotic prescribing for patients with acute cough, with no associated differences in rates of recovery,101 suggesting overuse.
Evidence of antibiotic overuse in LMICs is largely indirect. Global consumption of antibiotic drugs has risen by 36% between 2000 and 2010, with growing economies such as Brazil, China, India, Russia, and South Africa accounting for 76% of this increase.102 The extent to which this increase represents overuse is not known, however, a 2015 systematic review12 of medication use in China and Vietnam found evidence for antibiotic overuse in both countries. Furthermore, a 2005 systematic review11 of patterns of antibiotic use, which included studies from around the globe, found high rates of inappropriate administration, including substantial patient consumption of so-called leftover antibiotics.
Similarly, a 2013 Cochrane review103 of the effect of interventions to improve antibiotic prescribing in patients admitted to hospital included studies from both HICs and LMICs, suggesting wide recognition of the problem of inappropriate antibiotic use, however, the review did not directly quantify prescribing rates.
In other clinical specialties, unexpectedly high prescribing rates for specific drugs in individual health systems suggests overuse. Bevacizumab, an expensive and generally ineffective treatment for breast cancer, is not recommended by the National Institute for Health and Care Excellence (NICE) in the UK, and its US Food and Drug Administration marketing authorisation for breast cancer was withdrawn. However, the drug is reimbursed by health insurers in Colombia for all (licensed and unlicensed) cancer indications at great expense to the country's health-care system.104 Similarly, erythropoiesis stimulating drugs, epoetin alfa and beta and darbapoetin alfa, have been widely and inappropriately used in Romania to treat ribavirin-induced anaemia in patients with Hepatitis C and organ transplantations, in the absence of supporting evidence.105"
Under-use is complex:
The prevalence of underuse due to financial barriers in LMICs is likely to be substantially worse, but data are more scarce. To monitor global access to health care and ensure comparability between countries WHO and the World Bank have recommended eight core tracer health service indicators: family planning, antenatal care, skilled birth attendance, child immunisation (three doses of diphtheria, tetanus and pertussis [DTP]-containing vaccine), antiretroviral therapy, tuberculosis treatment, and improved water sources and sanitary facilities.16
These health services are identified as essential and should be available universally in all countries, regardless of socioeconomic stage or epidemiological status. The report estimated that in 2013 more than 400 million people were still unable to access one or more of the following basic health services: women whose demand for family planning was not met, pregnant women who did not attend at least four antenatal visits (minus 38% to account for unintended pregnancies), infants who did not receive three doses of DTP-containing vaccine, HIV-positive adults and children not receiving HIV treatment, adults with new cases of tuberculosis not receiving tuberculosis treatment, and children aged 1â14 years not sleeping under an insecticide-treated bednet.16"
However, an important point is made about the under-use of non-pharmacological interventions:
" Particularly wasteful is the global failure to capitalise on effective non-pharmacological therapies, which, although less intensively marketed, are in many cases equally or more effective than their pharmacological counterparts. For example, pulmonary rehabilitation, which involves progressive exercise and education, has been shown to reduce hospital re-admissions and deaths for patients with chronic obstructive pulmonary disease by 70%; daily application of sunscreen can cut invasive melanoma rates by 50%; and insecticide impregnated bednets can prevent 50% of malaria cases.31
Unlike their pharmaceutical counterparts, non-drug treatments are less intensively studied, more poorly described in research, weakly regulated, and inadequately marketed, particularly when the treatment or prevention is cheap or free."
Patient non-adherence remains a major challenge:
" For example, secondary prevention with drugs and lifestyle changes following acute myocardial infarction has greatly improved outcomes, but a recent retrospective cohort analysis in the USA documented low adherence at 12 months after discharge for prescribed drugs: 66% of patients were taking their β blockers, 63% angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), and 66% statins.42
These findings are echoed in a multicountry survey of patients with a self-reported cardiovascular disease event in the past four years, where use of preventive medication was generally low.
Adherence was highest in HICs (antiplatelet drugs 62%, β blockers 40%, ACE inhibitors or ARBs 50% and statins 66%), but much lower in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased with reduction of country economic status (p for trend <0·0001 for every drug type).43"
There are many drivers of poor quality care:
" Although medical science research is presumed to ask questions and examine areas of interest that matter to patients and citizens, 85% of the global investment in biomedical research - US$240 billion in 2010 - is wasted on research that fails in that mission.74, 121, 128 Many trials are underpowered; study endpoints chosen by professionals often are of low priority for patients; questions of functional, social, and emotional wellbeing, adverse reactions, and long-term outcomes are disregarded; and academia rewards short-term successes and newsworthy results at the expense of results that are meaningful to health.74 Industry-sponsored trials might ask questions that are of little or no clinical value, or that are destined to yield results that are favourable to the sponsor's product.75, 129, 130 These tendencies naturally lead researchers and industry to seek widened denominators (so-called indication creep) for tests or treatments proven effective in one disorder."
Some of the levers identified also echo points made in relation to essential medicines policies:
* " Democratic engagement is both an intrinsic value and a crucial lever for change. Patients and the wider public should be involved in the effort to achieve the right care not only because they are both the recipients and ultimate payers, but also because actively engaging these individuals can increase legitimacy of efforts to determine the relative value of various investments in health care, from infrastructure to specific services that are covered."
* "Clinical professions must engage in robust, evidence-based guideline development and implementation. Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.57 The majority of CPGs are developed by medical professional organisations, government agencies, and non-profit organisations. When guideline recommendations are developed through a structured, evidence-based process and applied by clinicians accurately, the expected effect would be an increase in the use of appropriate services and reduction in the use of inappropriate or unnecessary services, thereby improving outcomes, and potentially reducing net spending."
* " Although HTA and associated economic evaluation processes have become indispensable, especially regarding the value-based purchasing of pharmaceuticals, these processes have predominantly focused their attention on new and emerging health services and technologies. Little capacity exists for assessing services and technologies that are already established within health systems, but that nevertheless offer no or low-value. This situation has been referred to as being - stuck with the old and overwhelmed by the new - Many countries are realising this shortfall, and expanding the focus of HTA to include reviews of well established services (health technology reassessment [HTRA]).39"
The conclusion of the final paper in the series is worth repeating in toto:
" The modern history of health care is littered with policy and practice inaction in the face of inappropriate care, often justified by an absence of evidence or uncertainty about what might result -Machiavelli's 'new order of things' 111 This lack of action should no longer be acceptable. Although the scale of the problem is vast and complex, a range of potentially effective remedies are available, with many more needed. Evidence-based medicine, HTA, shared decision making, and countless other movements have surely nudged health systems to a point whereby we must ultimately acknowledge that a decision not to act is still a decision, and one with implications for people's health.
As efforts to improve the delivery of care continue worldwide, we must recognise that if the objective is to improve health, delivery systems need to be properly scaled and adapted to local needs and socioeconomic conditions to be maximally effective. Furthermore, delivery system leaders should remain humble about their systems' contributions to health and should be unburdened from the task of substituting less effective medical spending for social spending. Transitions from the norm invariably cause conflict, but if efforts to achieve the right care are able to capture the full opportunity in front of us, the benefits to the wellbeing of patients, professionals, and the public as a whole are too great to condone inaction."
Coverage below is from Reuters as "fair use", followed by the editorial and two commentaries.
Regards
Andy