Over-therapy

from Wikipedia, the free encyclopedia
This article or section needs to be revised. Details should be given on the talk page. Please help to improve it , and then remove this flag.

Overtherapy is the Germanization of an Anglo-American term that stands for medical treatments that provide no additional benefit for alleviating disease symptoms or healing, as well as treatments for abnormal findings without disease value. Prescribing such unnecessary medical treatments involves not only unnecessary costs, but also health damage and death, as many treatments are not free from health risks. The term is not synonymous with the health science term "oversupply", as this only includes unnecessary, non-evidence-based and uneconomical, but not harmful treatments. In health science terminology, the latter are delimited as "incorrect care". In addition, oversupply is widely used, for example, for an oversupply of doctor's offices or in pension law. Overtherapy also includes services that in the specific situation also represent too much medical treatment if they do not produce any benefit and are harmful. The terminology “over-”, “under-” and “wrong care” also implies that all superfluous and wrong measures would always be borne by a welfare organization, which is an inadmissible assessment. Overtreatment is an important economic factor, as Germany is one of the countries in the EU with the highest percentage of health care spending in gross domestic product.

distribution

Over-therapy is very common. More than 90% of the therapies examined by the Cochrane Collaboration lack solid evidence of efficacy and patient benefit. However, there is no consensus on the frequency, as no generally applicable criteria are considered accepted. Frequencies are therefore often approximations, with the risk of statistical bias . In an American study in 2017, a frequency of 29% was stated, in some cases 89% is reached internationally. In particular, overtreatment affects expensive treatment methods.

Frequency of over-therapy according to Brownlee
Over-therapy %
Cervical cancer screening 55
Repeat ECG 52
Antibiotics for a viral infection 50
Gastroscopy 60
Chest -CTS 46
Hip replacement 34
Hysterectomy 70
Tumor markers in breast cancer 73

The German Medical Association , the Bertelsmann Foundation , the German Ethics Council and the German Society for Internal Medicine report in a position paper with the name: "The patient is not a customer" on economic disincentives, increased numbers of interventions and the expansion of indications as well as the implementation of non-indicated interventions , the hospital is not a commercial enterprise. "

At the beginning of 2017, the internationally best-known medical magazine " The Lancet " started with a series of articles on "right care" and documents the international problem. In one of the articles, Germany occupies a top position with 33% of unnecessary hospital treatments. The topic of overtherapy is the main topic at World Anesthesia Day 2017 in Austria. In the opinion of the Advisory Council on the assessment of the development in the health system in 2018, it is said that overtreatment is "the central medical and economic problem".

root cause

The causes of overtreatment in medicine are diverse and complex. Accordingly, attempts at treatment without guaranteed effectiveness are already being pushed in training and further education. Recommendations to refrain from treatment or to stop therapy are exceptions in textbooks and guidelines. Waiting is considered a sign of uncertainty and incompetence. The periods of time required for spontaneous healing are often thwarted by recommendations for a "rapid start of therapy" or a missing expiry date for treatments. Overtherapy arises from actionism, which already initiates treatments when sufficient self-healing powers of the organism have not yet taken hold or are still to be continued when the healing no longer requires support. Immediate administration of antibiotics for every bacterial infection represents excessive therapy, since in the great majority of cases the self-healing powers are sufficient and, in contrast to antibiotics, do not necessarily have negative therapeutic effects. This also applies to treatment that is too long, as is the case with antibiotics, if these are usually prescribed for more than three days or weeks. Overtreatment is also the order of the day, if not exclusively evidence-based measures are taken. Evidence-based therapies can also represent overtreatment if the same therapeutic effect could have been achieved with less effort. This is the case if z. B. an abscess is surgically split, although a drainage introduced through a puncture under local anesthesia would have produced the same healing effect. In recent decades, the unnecessary treatment of symptom-free people has increased as a result of newly defined clinical pictures, newly defined normal ranges for biometric measured values ​​and in early stages, without the patient benefit for such treatments in the long term could be proven. This includes medication for psychiatric illnesses, medication for lowering blood cholesterol and treatments for locally limited prostate cancer. Overtherapy is also promoted to a very large extent by an expansion of diagnostic procedures ("overdiagnosis"), which bring to light findings that are often not considered to be of disease value, but which are nevertheless treated as deviations from the normal.

Four complexes of causes for overtreatment are described:

1. Bad economic incentives. In Germany's health system, remuneration in both the outpatient and inpatient areas is linked to the performance of treatments. Due to the higher income prospects for doctors and clinics, this must inevitably lead to an increase in treatment measures and thus to over-therapy. A volume expansion is often reinforced by degression regulations for tariffs when the number increases, as well as minimum volume regulations as a prerequisite for implementation. Another economically motivated factor is risk surcharges for concomitant illnesses, as this means that treatments are also carried out for people with an increased risk profile, which it is often better to avoid. The proportion of people over 65 years of age in operations in Germany is already 40%, although this group of people account for 90% of deaths after operations. In addition, there are also supply-driven expansions of treatment, which is also the result of an increase in the number of doctors by 50% in 25 years with advancing sub-specialization.

2. Gaps in knowledge, misbelief by patients and relatives,

3. the imbalance of doctor-patient roles ,

4. A fear of legal consequences if not all conceivable therapy methods are used.

The authors of the Lancet article explain the main causes:

Many doctors lead to many doctor visits, many intensive care units lead to many intensive care treatments. Where hospital groups determine the treatment orientation themselves, there is an oversupply of high-priced treatment methods (catheter laboratory, operating theater ) and an undersupply of less profitable therapies (e.g. palliative care).

So they conclude: The most important factor against overtreatment is to reduce the greed of the medical industry through structured fee schedules with a view to patient welfare. Prestige and striving for profiling also play a role if the number of treatments is increased beyond a reasonable level. Anyone who can demonstrate many treatments and thus also many "cures" through the use of therapies for harmless diseases and self-healing processes is considered competent and promotes patient influx and reputation. Exaggerated healing promises do the rest.

Clinical manifestations

Extension of definition of disease

In over 60% of the medical guidelines examined, an expansion of the definition of illness was found over time, and previously healthy people are defined as sick.

The lowering of the limit values ​​for cholesterol is widely discussed. For example, many more previously “healthy” people receive medication for lipid metabolism disorders with only questionable benefits, but the risk of over-therapy increases. The lowering of normal values ​​of kidney function - originally only intended to adjust the dose of medication - has also led to more healthy "kidney patients". Approximately every third elderly person with advanced kidney damage (IIIa) defined in this way has no urine markers whatsoever for real kidney damage.

Therapy guidelines

In the therapy guidelines of the Working Group for Gynecological Oncology (AGO), bevacizumab is recommended for breast cancer. Internationally, this is not considered sensible, for example the National Institute for Health and Care Excellence (NICE) in the UK. The US Food and Drug Administration has even withdrawn the approval here.

Preventive medicine

The benefit of cancer screening is controversial.

In South Korea, ultrasound cancer screening was performed 15 times more frequently for a long period. It has not reduced the mortality rate from thyroid cancer. In contrast, there was a real "cancer epidemic", many more thyroid cancers were discovered. 99.7% of these diagnoses were ultimately assessed as misdiagnoses. Accordingly, the patients often received dangerous and harmful overtreatment.

Heart medicine

Special problems are also described in heart medicine (cardiology), in some studies 30% of the coronal angiographies are inadequate, there are sometimes regional differences by a factor of 10. It could be shown that 55% of the angioplasties (insertion of a small mesh to keep the vessel open) would be avoided. For years, Germany has been the global leader in the frequency of coronary surgery. In terms of hospital mortality, on the other hand, Germany ranks 25th out of 28 industrial nations. This is not mentioned in the current German Heart Report 2016. In the lancet article, Germany occupies a top position with 33% of unnecessary hospital treatments. Even the Tagesschau put the problem in a nutshell at the end of 2018: “In no other country in Europe is a stent inserted as often as in Germany. It's a profitable business for the clinics. "

Overtherapy at the end of life

In many cases, overly aggressive cancer treatment at the end of life is documented, in young patients in the last 30 days of life about 75%. But other procedures are also clearly criticized by international scientists, such as the aimless PEG system, chemotherapy that shortens life, radiation treatment shortly before the end of life, useless medication, ineffective intensive therapy at the end of life, or aimless intravenous nutrition. In contrast, palliative care was only provided at the end of life in 2%.

Overtherapy in cancer

The evaluation of a German university clinic shows that cancer sufferers still receive a high degree of overtreatment in the last days of life. Chemotherapy, blood washing, operations, intensive treatment, and even resuscitation were common among dying cancer patients. Your chance of even leaving the hospital alive is well below 10%, most of the time with severe brain damage. About every third cancer patient dies in the intensive care unit.

A London research group has examined the long-term success of newly approved cancer treatments and comes to the following results:

Of the 68 treatments tested, 61 (90%) were used exclusively for a “palliative indication” - in other words, there was largely no prospect of a cure. Above all, however, cancer sufferers in advanced stages of the disease want to maintain or improve their quality of life. However, this was not investigated as a primary goal in any of the 68 areas of application tested. Even as a side effect, only partial improvements in quality of life were shown in only 7 (10%) of the substances. For example, the improvement in shortness of breath, but not the pain, led to the approval of a cancer drug. In the follow-up period of an average of 5.4 years, only 2 substances (2.9%) showed an increase in life with improved quality of life. While 24 (35%) substances demonstrated a lifetime extension upon approval, after long follow-up observation it was only 26 (38%). The extension of the lifetime was between 1 and 5.8 months, on average 2.7 months. Ultimately, the scientists rated the lifespan extension as relevant for only 11 (16.2%) indications. The study was widely discussed in the media. While experts are calling for a change in the approval conditions, the Federal Ministry of Health sees no need for this.

The authors conclude that when expensive drugs are approved and paid for in health systems without clinically meaningful services, individual patients can be harmed, critical resources wasted, and the provision of equitable and affordable health care undermined.

Cancer sufferers generally have many stressful complaints, fears and hardships, not only in the advanced stages of the disease. It has been undisputed for years that palliative care teams should also be provided with care as soon as possible. There are American and European recommendations for this.

Overtherapy in intensive care medicine

While the clinics used to be able to claim their costs based on the length of stay (so-called cost recovery principle) at the end of each year, the new DRG system (diagnosis-related groups) determines a fee on the basis of a diagnosis mix and the procedures carried out: the worse the disease and the more technical the procedure, the higher the proceeds. Many senior physicians participate in lucrative interventions or in clinic profits through bonus contracts. This creates false incentives in some contracts, where a share of 15% of the DRG proceeds was agreed. While the German Medical Association and legislators outlaw these contracts and urge voluntary renunciation, in 2015 97% of the new chief physician contracts still had corresponding clauses. In a survey of doctors and clinic managers, the majority of doctors admitted overtreatment (doctors agreeing in%). For economic reasons ...

... cardiac catheters or colonoscopies are performed that are not medically necessary (69%).

... patients are operated on, although this was not necessary (75%).

... is the ventilation duration or similar determined by the remuneration (71%).

... the time of discharge is chosen (58%).

... patients are admitted who do not necessarily belong in the hospital. (94%)

Avoidance

As a remedy against overtreatment, the following measures are brought into play:

  • Restrict treatment reimbursement to evidence-based approaches
  • Decoupling of remuneration from the implementation of measures
  • Appreciation of diagnostic medicine, especially so-called "speech medicine"
  • performance-based remuneration models
  • Introduction of warranty periods for treatments
  • Recourse models for practitioners
  • Reimbursement principle for the insured
  • Deductibles, practice and emergency fees
  • Quantity restrictions on treatments
  • Age limits for medical treatments.

consequences

Too much medicine does not lead to better health, but is harmful. Paracelsus already stated this:

All things are poison and nothing is without poison; the dose alone makes a thing not be poison.

Unwanted interventions or interventions that are not indicated are painful, have side effects and often do not lead to an improvement in health: When comparing the data from colon cancer sufferers who were treated in regions with a greater density of doctors and clinics than less, it was noticed that they were Seeing a doctor more often, going to the specialist more often, arranging more examinations and more minor interventions and clinical treatments, especially intensive care. This more medicine did not lead to greater satisfaction or better health. In the group with more intensive treatment the mortality was even higher.

Overtreatment not only harms patients, nursing staff and subordinate doctors are also affected: 91% of the clinicians surveyed reported overtreatment. The risk for burnout was almost four times as high and for termination it was 7.4 times as high.

Assistance

Patients are advised to express their will by means of a health care proxy and living will. In addition, a second opinion should always be obtained from an independent expert or the family doctor before critical or high-priced treatments .

Countermovements

Internationally there are some initiatives, in Great Britain the “do not do” list, in the USA the choosing wisely campaign, or in Germany recently the initiative “smart decisions”. However, the German surgeons did not participate in the latter, arguing that there was no problem. In Europe there was the first major congress on the problem in Vienna in February 2018 (36th Vienna Intensive Care Days), in Germany on May 17, 2018 in Berlin (care congress: A lot doesn't always help a lot ).

In Germany, MEZIS deals with non-medical influencing factors on doctors. In the USA, the Lown Institute has taken on the problem and publishes new findings every week:

Here, three important changes are called for, and the WHO is even approached : a good education of the population about less useful treatments by independent institutes, the effective individual education of the patient as well as the involvement of his decision and the critical examination of new procedures e.g. by means of EBM.

The pharmaceutical letter sees false monetary incentives as the cause of the over-therapy and warns of changes. It ends with the conclusion that you want to be on the right side. Solid medical care - listening to the patient, making decisions together, and reading the literature critically - is inexpensive, adequate, and produces better results. More and more we need defenders of these simple foundations. To be against wasting resources in the wrong place, overabundance of medical measures and thereby endangering patients does not mean to be against individual decision and therapeutic progress.

The Working Group of Scientific Medical Societies (AWMF) - Germany’s most important guideline committee - clearly criticizes overtreatment, especially due to false incentives in clinic financing: negatively impact and endanger patient care. There are false incentives against patient-oriented, scientific medicine through the remuneration system, the number and equipment of hospitals or specialist departments and their basic funding. "

literature

Individual evidence

  1. ↑ Shannon Brownlee: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer . 1 ed. Bloomsbury USA, New York 2008, ISBN 978-1-58234-579-6 ( online [accessed October 12, 2017]).
  2. ↑ File: Current healthcare expenditure, 2014 YB17.png. Retrieved October 12, 2017 .
  3. ↑ Padhraig S. Fleming, Despina Koletsi, John PA Ioannidis, Nikolaos Pandis: High quality of the evidence for medical and other health-related interventions was uncommon in Cochrane systematic reviews . In: Journal of Clinical Epidemiology . tape 78 , October 2016, ISSN  1878-5921 , p. 34-42 , doi : 10.1016 / j.jclinepi.2016.03.012 , PMID 27032875 .
  4. ↑ Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou: Evidence for overuse of medical services around the world . In: The Lancet . tape 390 , no. 10090 , p. 156-168 , doi : 10.1016 / s0140-6736 (16) 32585-5 ( online [accessed September 3, 2017]).
  5. ↑ Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou: Evidence for overuse of medical services around the world . In: The Lancet . tape 390 , no. 10090 , July 8, 2017, p. 156–168 , doi : 10.1016 / S0140-6736 (16) 32585-5 ( online [accessed September 4, 2017]).
  6. ↑ Central Ethics Commission: Medical Action Between Professional Ethics and Economization. The example of the contracts with leading hospital doctors. (No longer available online.) May 24, 2017, archived from the original on September 3, 2017 ; accessed on September 3, 2017 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.zentrale-ethikkommission.de
  7. ↑ Central Ethics Commission: Medical Action Between Professional Ethics and Economization. The example of the contracts with leading hospital doctors. (No longer available online.) May 24, 2017, archived from the original on September 3, 2017 ; accessed on September 3, 2017 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.zentrale-ethikkommission.de
  8. ↑ : Patient welfare as an ethical benchmark for the hospital. (No longer available online.) Archived from the original on October 27, 2017 ; accessed on September 3, 2017 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.ethikrat.org
  9. ↑ The patient is not a customer, the hospital is not. Retrieved September 3, 2017 .
  10. ↑ Redirecting. Retrieved September 3, 2017 .
  11. ↑ Oberösterreichische Nachrichten: In many cases dying is only delayed . ( Online [accessed October 12, 2017]).
  12. ↑ Needs-based management of health care. (PDF) Advisory Council on the Assessment of Developments in the Health Care System, accessed on November 29, 2018 .
  13. ↑ Redirecting. Retrieved September 3, 2017 .
  14. ^ Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug: Drivers of poor medical care . In: The Lancet . tape 390 , no. 10090 , July 8, 2017, p. 178–190 , doi : 10.1016 / S0140-6736 (16) 30947-3 ( online [accessed September 4, 2017]).
  15. ↑ Raymond N. Moynihan, Georga PE Cooke, Jenny A. Doust, Lisa Bero, Suzanne Hill: Expanding Disease Definitions in Guidelines and Expert Panel Ties to Industry: A Cross-sectional Study of Common Conditions in the United States . In: PLOS Medicine . tape 10 , no. 8 , August 13, 2013, ISSN  1549-1676 , p. e1001500 , doi : 10.1371 / journal.pmed.1001500 ( plos.org [accessed September 3, 2017]).
  16. ^ Financing cancer care and control: Lessons from Colombia. (PDF) Retrieved September 3, 2017 .
  17. ^ Hyeong Sik Ahn, Hyun Jung Kim, H. Gilbert Welch: Korea's thyroid cancer "epidemic" - screening and overdiagnosis . In: The New England Journal of Medicine . tape 371 , no. 19 , November 6, 2014, ISSN  1533-4406 , p. 1765-1767 , doi : 10.1056 / NEJMp1409841 .
  18. ↑ Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou: Evidence for overuse of medical services around the world . In: The Lancet . tape 390 , no. 10090 , July 8, 2017, ISSN  0140-6736 , doi : 10.1016 / S0140-6736 (16) 32585-5 ( thelancet.com [accessed September 3, 2017]).
  19. ↑ Criticism of stents - dubious benefit, high price
  20. ↑ Aggressive care at the end-of-life for younger patients with cancer: Impact of ASCO's Choosing Wisely campaign. Retrieved September 3, 2017 .
  21. ↑ Burkhard Dasch, Helen Kalies, Berend Feddersen, Caecilie Ruderer, Wolfgang Hiddemann: Care of cancer patients at the end of life in a German university hospital: A retrospective observational study from 2014 . In: PloS One . tape 12 , no. 4 , 2017, doi : 10.1371 / journal.pone.0175124 , PMID 28384214 , PMC 5383201 (free full text).
  22. ^ Courtney Davis, Huseyin Naci, Evrim Gurpinar, Elita Poplavska, Ashlyn Pinto: Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by the European Medicines Agency: retrospective cohort study of drug approvals 2009–2013 . In: BMJ . tape 359 , October 4, 2017, ISSN  0959-8138 , p. j4530 , doi : 10.1136 / bmj.j4530 , PMID 28978555 ( online [accessed October 12, 2017]).
  23. ^ Ethical analysis of life-extending treatments. Retrieved October 12, 2017 .
  24. ↑ Integration of Palliative Care Into Standard Oncology Care. Retrieved September 3, 2017 .
  25. ↑ Editor Deutsches Ärzteblatt: Medical ethics: Economic thinking must not be in the foreground . ( Online [accessed September 3, 2017]).
  26. ^ Deutscher Ärzteverlag GmbH, editorial office of the Deutsches Ärzteblatt: Economization of patient-related decisions in hospitals . ( Online [accessed December 2, 2017]).
  27. ^ The Implications of Regional Variations in Medicare Spending: Health Outcomes and Satisfaction with Care . In: Annals of Internal Medicine . tape 138 , no. 4 , February 18, 2003, ISSN  0003-4819 , p. I-49 , doi : 10.7326 / 0003-4819-138-4-200302180-00002 .
  28. ↑ Jason P. Lambden, Peter Chamberlin, Elissa Kozlov, Lindsay Lief, David A. Berlin: Association of Perceived Futile or Potentially Inappropriate Care With Burnout and Thoughts of Quitting Among Health-Care Providers . In: The American Journal of Hospice & Palliative Care . August 5, 2018, ISSN  1938-2715 , p. 1049909118792517 , doi : 10.1177 / 1049909118792517 , PMID 30079753 , PMC 6363893 (free full text).
  29. ↑ Matthias Thöns, B. Huenges, H. Rusche: avoid overtreatment . Ed .: The family doctor . tape 14 , 2016, p. 52 .
  30. ↑ Editor of the Deutsches Ärzteblatt: Smart decisions recommendations: Not a “must” for surgery at the moment . ( Online [accessed September 3, 2017]).
  31. ↑ The first: Video "Operating and cashing in - A clinic data crime thriller" - Report & documentation. (No longer available online.) June 19, 2017, archived from the original on September 3, 2017 ; accessed on September 3, 2017 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.ardmediathek.de
  32. ↑ Less is (very often) more! November 19, 2018, accessed December 8, 2018 .
  33. ↑ [1]