Finding things to stop doing...

Early exponents of evidence-based medicine put forward an optimistic view of future healthcare, where the availability of robust information would allow clinicians to select the most effective treatments – and to stop doing things which were shown not to work.  But this last part has proved elusive.

A recent paper by Sarah Garner and colleagues from NICE tested out the use of Cochrane reviews to identify low value practices which might inform local disinvestment decisions http://jhsrp.rsmjournals.com/content/18/1/6.full.  NICE had been criticised by the Health Select Committee in 2008 for lack of progress in supporting NHS drive for efficiency savings.   Very few technologies had been identified as absolute candidates for disinvestment.  Indeed, the authors noted that only two topics featuring low value practices had been selected in the last six years for full NICE guidance development.   A really interesting contention was explored in this paper – greater certainty and levels of evidence were required for a `do not recommend’ decision by NICE, than a treatment option left to the discretion of the clinician.  This is because of the inevitable challenge (in the courts) if existing treatments are discontinued.

And the UK is not alone.  The same paradox was noted by Chris Henshall speaking at the Health Technology Assessment International conference last year.   He remarked wryly that the search for low-hanging fruit (ineffective procedures) often ignored the fact that they were still firmly attached to the tree.  He did however commend NICE for one of the few examples of a `managed exit’ for low value procedures, with guidance on the use of prophylactic antibiotics for endocarditis.

Other attempts to throw light on disinvestment in the NHS include an NIHR-funded study by William Hollingworth in Bristol http://www.netscc.ac.uk/hsdr/projdetails.php?ref=09-1006-25.  This study uses routine data to identify high levels of practice variation as a proxy to identify procedures of uncertain clinical value.  In this way, he draws on classic Wennberg notions of uncertainty or preference-sensitive care for procedures such as radical prostatectomy.  Hollingworth goes on to work up guidance for local commissioning groups and explore practice and beliefs on de-commissioning. 

It reminded me too of wider NIHR-funded work on commissioning practice and the use of evidence http://www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1808-244.   Some interesting observational research on decision-making by commissioning organisations was striking in the disproportionate effort given to certain areas of activity.  For instance, individual funding requests (for exceptional treatments for individual patients) required high levels of scrutiny and evidence for quite marginal areas of spend and activity.   

Muir Gray and others have long bemoaned the lack of information or informed decision-making about huge areas of clinical care, from epilepsy to pain management.  This kind of inverse evidence law helps to explain just some of the difficulties in trying to realise savings in the NHS.    

Some of the most encouraging developments to reduce waste and enhance value in recent years has come with programme budgeting and pathway redesign.  This might include shifting care, role substitution (such as nurse consultant-led clinic and triage centres) and reviewing thresholds and optimal levels for stepped care.   Examples such as the initiative in Oldham to re-shape services for rheumatology, orthopaedics and chronic pain suggest the power of using evidence with engagement from clinicians, managers and patients to re-think care processes http://www.rightcare.nhs.uk/downloads/Right_Care_Casebook_oldham_IPH_april2012.pdf

There has been a belief that to identify ineffective practice or treatments `the evidence will speak for itself’.  Progress to date suggests that it is difficult to make absolute assertions about interventions of low clinical value.  A more engaged process to eliminate waste across whole programmes of clinical activity is likely to yield more fruit – with the clinicians shaking the tree.