Experts focus on most important recommendations to scale back care for chronic conditions
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A panel of 25 physicians from specialties such as primary care, cardiology and endocrinology prioritized and revised recommendations to deintensify routine care in several areas, including diabetes, pain, cancer and heart disease.
“Much of health care involves established, routine use of medical services for chronic conditions or prevention,” Eve A. Kerr, MD, MPH, a professor of general medicine at the University of Michigan Institute for Healthcare Policy & Innovation, and colleagues wrote in JAMA Internal Medicine. “Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing.”
Kerr and colleagues reviewed existing guidelines and recommendations primarily published between 2011 and 2016 to prioritize them. Expert panels examined and synthesized the evidence, suggested ways the recommendations could be improved, and assessed the validity of the recommendations. Overall, 37 recommendations were validated as “high-priority deintensification recommendations,” according to the researchers.
Some actionable recommendations for deintensification included the following:
- Stop or decrease doses of insulin, thiazolidinediones and/or sulfonylureas within 3 months of a low HbA1c level in patients aged 65 years and older with an HbA1c level lower than 7% who are at high risk for hypoglycemia.
- Decrease the opioid dose or justify the continuation of the current dose in patients with chronic, noncancer pain who are on a long-term daily dose of 90 morphine milligram equivalents or more daily. Patients receiving hospice or palliative care are excluded from this recommendation.
- Do not screen more often than every 10 years with colonoscopy, every 5 years with sigmoidoscopy or yearly with a fecal immunochemical test or fecal occult blood test in patients with an average risk for colorectal cancer. This excludes patients whose prior colonoscopy was incomplete due to inadequate bowel preparation.
- Stop annual or more frequent screening with stress ECG, stress echocardiography or stress myocardial perfusion imaging in asymptomatic adults at low risk for coronary heart disease events.
- Do not use echocardiography for screening more often than every 3 years in adults with mild, asymptomatic native valve disease.
In a related editorial, Raj Mehta, MD, associate program director of the family medicine residency at AdventHealth in Florida, and Richard Lehman, BM, BCh, honorary professor of shared understanding of medicine at the Institute of Applied Health Research at the University of Birmingham, England, said the study by Kerr and colleagues “offers a demonstration of how the guideline process can identify and validate recommendations for deintensification.”
However, there are limitations, they said.
“Nuances that may influence decision-making, such as uncertainty in the absence of evidence or variations in efficacy and effect size, are often lost when translating evidence to recommendations,” Mehta and Lehman wrote. “Requiring consensus among experts makes it harder to challenge low-value care for specialties with favored interventions.
Recommendations that dictate decisions for patients and clinicians can unintentionally appear to discourage shared decision-making, making it harder to gain buy-in and adoption.”
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Margot Savoy, MD, MPH
It is well established that the number of preventive care recommendations in primary are staggering. One study showed that to implement all of U.S. Preventive Task Force recommendations would take 7 hours per working day.
We also know that stopping screening is a difficult decision for both the physician and the patient. Neither wants to expose the patient to harm, but there can be unintended harms in screening patients with guidelines not within the patient’s age group.
The Choosing Wisely initiative (and other similar program) has been great at encouraging dialogue between doctors and their patients about ways to avoid unnecessary medical tests, treatments and procedures by providing lists of things to consider stopping or not to start with supporting evidence. These lists quickly became too long and challenging for doctors to take in and implement. When you know you cannot do it all, figuring out which ones are the highest yield for the person in front of you is critical. The key is being confident that the prioritization is based on sound data/evidence.
This study seems interesting because it appears to be trying to boil down these de-escalation recommendations and guidelines into more actionable statements and prioritize them based on agreement within the expert panels.
Though the individual recommendations (eg, using the lowest dose of opiates) are reasonable, I’m not convinced that an expert panel agreeing that rewriting a recommendation to use more action-oriented words practically makes my job all that much easier. I understand what they were working toward, but what I would have needed to make delivering care easier would have been a prioritization score that was based on how confident we are that implementing this recommendation would either save the patient’s life or improve their quality of life. That isn’t what it seemed like they were looking for.
For most of the examples shared in the paper, the original language didn’t appear to be overly complicated to me, so the adaptations — while more streamlined —added little to my understanding of what the original recommendation to de-intensify was asking me to do. One potential benefit could be that the revised wording may make it easier to write code for electronic medical records to either trigger a best practice alert so you know to review with the patient. While I don’t think this work saves me much time in delivering care, I do appreciate the attempt to model what actionable guideline language could look like in the future.
Reference: Yarnall KSH, et al. Am J Public Health. 2003;doi:10.2105/ajph.93.4.635.
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