Change of Thinking About Medicine -- Providing the 'Right Care'

Zosia Chustecka

January 10, 2017

A change of thinking about healthcare is outlined in a series of articles in a special edition of the Lancet. The articles report on the huge problems of both overuse and underuse of medicine and champion the idea of "right care."

So what is right care?

In its simplest definition, Lancet editors explain in an introductory comment, it is care "that weights up benefits and harms, is patient-centered (taking into account individual circumstances, values and wishes), and is informed by evidence, including cost-effectiveness."

A more detailed definition, given in one of the articles, describes right care as being "tailored for optimizing health and wellbeing by delivering what is needed, wanted, clinically effective, affordable, equitable, and responsible in its use of resources."

"This is an insanely ambitious definition, and yet in many ways, this is what we would all say is ideal," commented Vikas Saini, MD, president of the Lown Institute, Brookline, Massachusetts, and author on many of the articles in the series.

Speaking at a launch meeting in London, he said the series is a call to action.

The articles include detailed discussions of overuse and underuse of medicine. Both are extensive problems that occur across countries and within institutions, and they can even occur in the same patient.

Both cause suffering, Dr Sinai and colleagues write, resulting in "physical, psychological and social harms for patients and wasteful misallocation of resources for society."

Overuse of medicine is defined as the "the provision of medical services that are more likely to cause harm than good." Examples include inappropriate use of antibiotics, ineffective treatment in the intensive care unit at the end of life, and inappropriate surgical procedures, such as hysterectomies, cesarean deliveries, and total knee replacements (more that 20% in Spain and 30% in the United States are inappropriate).

Underuse of medicine is defined as "the failure to use effective and affordable medical interventions." Examples include low use of antenatal corticosteroids for preterm delivery (less than 50% worldwide) and underuse of anticoagulation in patients with nonvalvular atrial fibrillation who are at high risk for stroke (found to be used in fewer than 50% of such patients in a French nursing home).

"Because overuse and underuse are so deeply entrenched in contemporary medical care, and because the harms are so considerable, efforts to remedy these issues are a moral imperative and a political duty," comments Adam Elshaug, PhD, from the Menzies Center for Health Policies at the University of Sydney, in Australia, with colleagues.

"Focusing more of the world's attention towards redressing low-value care now becomes an urgent task," they add.

"This landmark Lancet Series on overuse and underuse constitutes a call-to-arms to improve health care globally by better matching care to needs, and practice to science. Reducing unwarranted, useless, and, therefore, harmful care is an important part of that agenda," writes Don Berwick, director of the Institute for Health Improvement, in an accompanying commentary.

Lancet. Published online January 8, 2017. Right Care series abstracts

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