Tiago Villanueva: quaternary prevention


Tiago Villanueva: quaternary prevention

Tiago_VillanuevaThe primary care innovation seminars group, a primary healthcare think tank that was created in Spain in 2005, convened this weekend in Barcelona. The group used to meet several times a year in Madrid. This year, group members gathered for the first time outside the Spanish capital, with the added bonus of the presence of many leading GPs from around the world, who were in Barcelona for the annual meeting of the World Organization of Family Doctors International Classification Committee (WICC). Many of the WICC members were speakers at the seminar, including Juan Gérvas, a Spanish GP and leader of the primary care innovation seminars group.
Domhnall Macauley and I have previously mentioned the concept of quaternary prevention, but few can describe it like Marc Jamoulle, a Belgian GP and one of the world’s leading experts in quaternary prevention, who says it is all about “the action taken to identify the patient at risk of overmedicalisation, to protect him from new medical interventions, and to suggest other interventions to him, which are ethically acceptable.”
The concept of quaternary prevention has been gaining momentum among the primary health care academic community over the last few years, but it has been known for decades. Sometimes, the best approach to a health problem is acknowledging when to avoid providing unnecessary healthcare. For example, one participant in the seminar said that for the last 30 years a military hospital in the United States has considered it acceptable not to treat burns patients with burns in over 95% of their body surface due to the poor prognosis of such patients.
Gustavo Gusso, president of the Brazilian Society of Family Medicine, said that in order to successfully teach quaternary prevention, we need to produce relevant scientific information, including protocols that start with the symptom rather than with the disease. He pointed out that even though diagnosis and disease centered protocols have many limitations, we were failing to do better.
Juan Gérvas added that, even though many patients these days have multiple health problems, conferences about single health problems and diseases remain the norm (for example, diabetes), while conferences about multimorbidity remain rare. So he called for participation in a meeting in 2012 organised by the Spanish Primary Care Network about schizophrenic diabetic patients, and wondered if anyone was aware of guidelines for diabetic patients with schizophrenia. No one responded.
One of the key ideas Gérvas conveyed was that it is pivotal to keep patients away from the health system when they don’t need healthcare at all, as well as being extremely cautious about the dangers of expanding access to health services. For example, introducing radiology services in primary health care may cause unnecessary harm if used excessively.
He also mentioned the example of the King of Spain, Don Juan Carlos, who goes to Barcelona every year to have a “check-up,” encouraging many Spanish people to do the same and therefore to potentially damage their health. In the case of the King, he said that a pulmonary nodule was found last year that was most likely benign, but which still triggered potentially avoidable surgery that subsequentely prevented the King from attending the football World Cup in South Africa. Vicente Ortún, dean of the Faculty of Economics of the Pompeu Fabra University, in Barcelona, emphasised that quaternary prevention increases both effectiveness and equity.
Leading Spanish health economist Beatriz López-Valcarcel, from the University of Las Palmas, in the Canary Islands, explained that even though assisted reproduction was successful only in about 7% of Australian women aged between 40 and 44 years, the Australian Government still decided to keep funding it. It may not make sense to clinicians to fund potentially useless medical interventions, but she stressed the idea that the goal of the health system was not to save, but rather to attain a balance between health benefits and risks, and between effectiveness and costs. So keep this in mind the next time you hear about politicians making decisions about the health system that don’t seem to make any sense.
Tiago Villanueva is a GP based in Portugal and a former BMJ clegg scholar and editor, Student BMJ. He personally paid for all the travel expenses to attend the seminar in Barcelona.

SIAP 2011: Prevención Cuaternaria, programa.


Los daños provocados por la prevención y las actividades preventivas.


Escépticos en Amazings 2011Image by wicho via FlickrLa prevención tiene una aureola positiva que con frecuencia lleva a ignorar sus efectos adversos. Las actividades preventivas son actividades sanitarias, y como tales tienen ventajas e inconvenientes. En este texto se estudian algunos ejemplos del daño que puede causar la prevención. No basta, pues, con la buena intención de “prevenir”. Hay que demostrar que los beneficios superan los perjuicios.
  • Los daños provocados por la prevención y las actividades preventivas. Gérvas, J., Pérez Fernández, M. Rev Innovación Sanit Aten Integrada. 2009; 1(4): 6. Descargar artículo completo aquí.
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Tratamientos psicológicos que dañan


DisturbiMentaliImage via Wikipedia
O de cuando “primum non nocere” no sólo es aplicable a los aspectos biológicos de las consultas.

Lilienfeld Psychological Treatments That Cause Harmhttp://www.scribd.com/embeds/60561644/content?start_page=1&view_mode=list&access_key=key-2otp3hakkrx7gl5ub7w3(function() { var scribd = document.createElement(“script”); scribd.type = “text/javascript”; scribd.async = true; scribd.src = “http://www.scribd.com/javascripts/embed_code/inject.js”; var s = document.getElementsByTagName(“script”)[0]; s.parentNode.insertBefore(scribd, s); })();

Designing a Smarter Patient


[medical]Edel Rodriguez

When given clearer information, patients weigh risks and benefits differently from their doctors.

“I’m comfortable with that,” or “No, it wouldn’t be comfortable for me.”
That’s what our patients often tell us when faced with a choice about taking a medication or undergoing a procedure. And the discussion usually stops there.
But what makes someone comfortable or uncomfortable with one treatment or another, or with no treatment at all? Where do these views come from? And how can patients make better decisions?
For answers, we spent four years interviewing scores of patients of different ages. We found that a host of powerful and often hidden influences, inside and outside the patient’s mind, can sway thinking and distort judgment. We also discovered that, by unmasking those influences, it is possible for patients to gain greater confidence and control over their medical decisions.
Consider the case of Susan Powell (not her real name), a nurse’s assistant now in her 50s. She had been healthy all her life, but when she turned 45, she decided to see a primary-care doctor. Susan ate healthy foods and was physically active, but she was a bit overweight, and her blood tests showed that she had high cholesterol. Her doctor prescribed a statin drug and asked her to come back in a month.


Statins are among the most commonly prescribed medications in the world. In the U.S. alone, more than 25 million people take the drugs to lower their cholesterol, which is a key factor leading to heart attack and stroke.
Soon after seeing her doctor, Susan spoke with an acquaintance at church who had developed muscle pain after starting to take a statin. Susan also thought of her father, who had high cholesterol and never took any medication for it. “People take too many pills,” he often told his children. He lived a long, full and active life.
Susan decided not to take the statin.
Many people decline treatment because they know someone who suffered from side effects or someone who lived well into old age without treatment. Stories deeply affect all of us, and they can make real the risks and benefits that might otherwise seem abstract—but they can also distort our vision by making the rare appear routine.
Statistics can help to put lessons drawn from stories into a larger context, letting us make a more considered choice than we possibly could by using narratives alone.
At Susan’s follow-up appointment a month later, her doctor told her that “by taking a statin pill, you’ll reduce your risk of a heart attack over the next 10 years by as much as 30%.” The risk of side effects, she continued, was very small, and the benefits far outweighed the risk. Susan promised to give it serious thought.
She continued to search for information, reading everything she could about cholesterol. What caught her eye was a government-sponsored link to a “10-Year Heart Attack Risk Calculator.”
She entered her age, total cholesterol number of 240, and “good” cholesterol (HDL) of 37. She was not a smoker, her blood pressure was fine, and she was on no medications. The result: “Risk Score: 1%: Means 1 of 100 people with this level of risk will have a heart attack in the next 10 years.”
This means that 99 of 100 people like me won’t have a heart attack in the next 10 years, Susan told herself. She started to feel much better. She had found a key number in health literacy: her risk for disease without treatment.
Without treatment, Susan’s risk for a heart attack was 1 in 100. If 1 in 100 women has a heart attack, that means 2 in 200 do, or 3 in 300. The statin treatment reduces risk by 30%, or about one-third.
Let’s apply that benefit to a group of 300 women like Susan, where three would have a heart attack without taking statins. If we treat them all, we would prevent one heart attack—because we protect one-third of those three. The other two women would still have a heart attack despite taking the medicine. The remaining 297 would not have had a heart attack even without the medication, so they wouldn’t benefit from taking it.
This statistic comes as a surprise to many people. When you hear that a statin lowers Susan’s risk by 30%, it sounds as if she is at a 100% risk of suffering a heart attack if she doesn’t take the medication.
Another component of health literacy is understanding the risks of a therapy. Statins cause muscle pain in 1% to 10% of people who take them. However, if we “flip” the frame, the number without any side effects is 90 to 99 out of 100, a much more reassuring statistic.
Advertisements for drugs may include statistics, but fundamentally these ads are designed to communicate a compelling tale. Over the weeks that followed her appointment with her physician, Susan paid particular attention to ads for statins. Once she started looking for them, they seemed to be everywhere.
In 2007, a team of researchers from the UCLA Medical Center and other medical centers studied prescription drug ads broadcast on national networks. They found that the average American TV viewer sees over 1,000 prescription drug ads in the space of a year. That’s 16 hours all told—much more time than the average person spends with his or her primary-care physician.
The study concluded that the large majority of TV ads fail to fulfill an educational purpose. But they clearly work, at least from the point of view of sales: Every $1,000 spent on advertising translated into 24 new prescriptions, according to an analysis by the House Energy and Commerce Committee.

Another illuminating study, conducted by researchers at the Dartmouth Institute for Health Policy and Clinical Practice, examined the impact of printed drug ads on patient preferences. One group was given actual ads. A second group received the same ads, except that the brief summary at the end of the text was replaced by a “drug-facts box.” The box presented information in a clear, accessible fashion, similar to the way we recalculated the benefits and risks of a statin for Susan.
The results of the Dartmouth research are impressive. Nearly two-thirds of the group that saw the original ads overestimated the benefits of the treatment. They believed it was 10 times more effective than it actually was. But nearly three-quarters of the participants who saw the information in the drug-facts box correctly assessed the actual benefits of the treatment.
Even more striking was another finding. When people were given readily understandable information about the statin’s actual benefit in preventing future heart disease, nearly twice as many said they wouldn’t take the drug in light of its side effects. When given clearer information, the patients weighed the risks and benefits differently from their doctors and were less likely to take the medication.
Susan Powell’s decision was not simple. More than five years later, her doctor continues to encourage her to take the drug, and she continues to say no—but now, at least, she can more fully explain why.

—Dr. Groopman and Dr. Hartzband are on the faculty of Harvard Medical School and the staff of Beth Israel Deaconess Medical Center, both in Boston. This essay is adapted from their new book, “Your Medical Mind: How To Decide What Is Right for You.