Progress in science and technology has helped to extend our life expectancy. We have learned to solve—and prevent—problems that were once deadly or at least extremely harmful. Logically, our expectations of the contributions made by research and its practical application continue to rise. But our expectations should be realistic too: we have to accept that science cannot solve all our problems. The idea is now widespread, for instance, that any physical problem can be treated. Some managers take the view that beliefs like this have led to society’s medicalization, a systematic and indiscriminate use of medical resources without regard to the fact that they are finite. To tackle this trend, we are seeing a different approach, one based on the principle of austerity. It asks the question: is doing something always better than not doing something?
Excessive medicine vs. parsimonious medicine
Faced with this dilemma, medicine has traditionally preferred to act—even when the effectiveness of a procedure is in doubt—rather than to refrain from acting. And this tendency toward excessive action can be seen both in countries where healthcare is in the hands of the private sector and in countries with public healthcare systems. According to the critics, excessive medicine poses both individual and social risks. First, we have iatrogenesis, meaning the medical complications that arise from the toxic or harmful effect of a treatment or diagnostic test. And then we have a waste of resources. As a result, excessive medicine is neither safer nor more efficient.
The parsimonious medicine seeks to stop using practices that evidence has shown to be of little or no value
The term parsimony can be used to mean frugality and moderation in spending and in this context parsimonious medicine is the medicine we apply with restraint and that seeks to stop using practices that evidence has shown to be of little or no value. Proponents contend that it should not be confused with rationing, which implies sacrificing beneficial measures for some patients in the name of the common good. Parsimonious medicine does not involve limitations on services. Instead, it maximizes their rationalization: avoiding unnecessary interventions, minimizing harm to patients, and curbing expenditure.
Strategies to reduce the overuse of healthcare services
The misuse of preventive, diagnostic, therapeutic and rehabilitation services have an obvious impact on the sustainability of the system, but also on people’s health: the risk is sometimes greater than the benefit. A number of initiatives are aimed at separating efficient practices from practices of little or no value, meaning practices that are quite often used automatically by the healthcare professional on the assumption that they are beneficial, while in reality the scientific evidence has cast doubt on them or refutes them.
The National Institute for Health and Clinical Excellence (NICE) promotes a list of Do not do recommendations. These are practical recommendations taken from their clinical guidelines and they identify which procedures should be discontinued completely or should not be used routinely. The ABIM Foundation, a North American medical association, launched the Choosing Wisely campaign to encourage providers and patients to discuss interventions that seem questionable. In Catalonia, the Catalan Agency for Health Information, Assessment and Quality (AQuAS) has implemented the Essencial project, which seeks to improve the quality of healthcare by eradicating measures not proven to be effective.
The Essencial project: adding value to clinical practice
The objective of the Essencial project is to determine which procedures to avoid because they contribute no value to the public’s health. The process is open to the professional community because their participation is crucial to the task of identifying and eradicating unnecessary or counter-productive practices. Healthcare staff can post their suggestions on the project website and refer to the list of discouraged practices and the reasons why these are on the list. Recommendations are prioritized in terms of the prevalence and burden of the disease, the frequency of use, the risk-benefit relationship, and the organizational impact.
The recommendations include not using alternating antipyretics for the symptomatic treatment of fever in children; ruling out routine screening mammograms for women under 50 if they have no additional risks for breast cancer; no longer taking preoperative chest X-rays in asymptomatic patients; and advising that carrying on with rehabilitation treatment for complications after a stroke for longer than twelve months does not improve the process of functional neurological recovery.
The Essencial project frees up resources for other procedures that do add value
Unlike similar initiatives around the world, the Essencial process also measures the impact on the system caused by applying the recommendations. And the impact differs according to the prevalence of the disease. For example, the misuse of antibiotics or diagnostic tests costs more than doing rehabilitation after a stroke for longer than a year. To implement the recommendations successfully and bring about a real change in clinical habits, there needs to be collaboration among healthcare professionals, managers, patients and the public administration. The ultimate goal of the Essencial project is to reassess the quality and effectiveness of our healthcare system and make it more sustainable by freeing up resources for other procedures that do add value.