Thursday, January 19, 2012

Reflexionem-hi

High-Value Testing Begins With a Few Simple Questions

Sabem que el valor de les proves diagnòstiques sorgeix de la informació marginal que aporten i la capacitat per modificar les probabilitats de patir una malaltia o el canvi en el seu curs. Per tant, el valor en si mateix és informació, un bé intangible crucial per a decidir el tractament. Tota prova diagnòstica té un cost, ara bé per tal que aquest cost acabi convertint-se en valor, de veritat, podem fer algunes preguntes clau que proposa l'Annals:
Did the patient have this test previously?
If so, what is the indication for repeating it?
Is the result of a repeated test likely to be substantively different from the last result?
If it was done recently elsewhere, can I get the result instead ofrepeating the test?
Will the test result change my care of the patient?
What are the probability and potential adverse consequences of a false positive result?
Is the patient in potential danger over the short term if I do not perform this test?
Am I ordering the test primarily because the patient wants it or to reassure the patient?
If so, have I discussed the above issues with the patient?
Are there other strategies to reassure the patient? 
i el darrer paràgraf clau:
Data suggest that unnecessary testing abounds. The Congressional Budget Office has estimated that up to 5% of the nation’s gross national product is spent on tests and procedures that do not improve patient outcomes (6). The sixth edition of the ACP Ethics Manual specifically calls out responsible stewardship of resources as an ethical responsibility of physicians (7) and has been lauded for doing so (8). Such stewardship requires substantial and persistent effort with some hard decisions along the way. Addressing a few simple questions before ordering a test seems to be a reasonably easy way to start the journey toward high-value care.
A tots aquells que vulguin una retallada selectiva i no pas lineal, tal com alguns hem vingut demanant des de l'inici, el mateix Annals ofereix la llista de proves diagnòstiques en situacions clíniques que aportaran poc valor. Només fa falta llegir-ho i dur-ho a la pràctica. Qui s'hi apunta?

PS. La llista de proves diagnòstiques inacurades
1. Repeating screening ultrasonography for abdominal aortic aneurysm following a negative study
2. Performing coronary angiography in patients with chronic stable angina with well-controlled symptoms on medical therapy or who lack specific high-risk criteria on exercise testing
3. Performing echocardiography in asymptomatic patients with innocent-sounding heart murmurs, most typically grade I–II/VI short systolic, midpeaking murmurs that are audible along the left sternal border
4. Performing routine periodic echocardiography in asymptomatic patients with mild aortic stenosis more frequently than every 3–5 y
5. Routinely repeating echocardiography in asymptomatic patients with mild mitral regurgitation and normal left ventricular size and function
6. Obtaining electrocardiograms to screen for cardiac disease in patients at low to average risk for coronary artery disease
7. Obtaining exercise electrocardiogram for screening in low-risk asymptomatic adults
8. Performing an imaging stress test (echocardiographic or nuclear) as the initial diagnostic test in patients with known or suspected coronary artery disease who are able to exercise and have no resting electrocardiographic abnormalities that may interfere with interpretation of test results
9. Measuring brain natriuretic peptide in the initial evaluation of patients with typical findings of heart failure
10. Annual lipid screening for patients not receiving lipid-lowering drug or diet therapy in the absence of reasons for changing lipid profiles
11. Using MRI rather than mammography as the breast cancer screening test of choice for average-risk women
12. In asymptomatic women with previously treated breast cancer, performing follow-up complete blood counts, blood chemistry studies, tumor marker studies, chest radiography, or imaging studies other than appropriate breast imaging
13. Performing dual-energy x-ray absorptiometry screening for osteoporosis in women younger than 65 y in the absence of risk factors
14. Screening low-risk individuals for hepatitis B virus infection
15. Screening for cervical cancer in low-risk women aged 65 y or older and in women who have had a total hysterectomy (uterus and cervix) for benign disease
16. Screening for colorectal cancer in adults older than 75 y or in adults with a life expectancy of less than 10 y
17. Repeating colonoscopy within 5 y of an index colonoscopy in asymptomatic patients found to have low-risk adenomas
18. Screening for prostate cancer in men older than 75 y or with a life expectancy of less than 10 y
19. Using CA-125 antigen levels to screen women for ovarian cancer in the absence of increased risk
20. Performing imaging studies in patients with nonspecific low back pain
21. Performing preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology
22. Ordering routine preoperative laboratory tests, including complete blood count, liver chemistry tests, and metabolic profiles, in otherwise healthy patients undergoing elective surgery
23. Performing preoperative coagulation studies in patients without risk factors or predisposing conditions for bleeding and with a negative history of abnormal bleeding
24. Performing serologic testing for suspected early Lyme disease
25. Performing serologic testing for Lyme disease in patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease
26. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes
27. Performing imaging studies in patients with recurrent, classic migraine headache and normal findings on neurologic examination
28. Performing brain imaging studies (CT or MRI) to evaluate simple syncope in patients with normal findings on neurologic examination
29. Routinely performing echocardiography in the evaluation of syncope, unless the history, physical examination, and electrocardiogram do not provide a diagnosis or underlying heart disease is suspected
30. Performing predischarge chest radiography for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery
31. Obtaining CT scans in a patient with pneumonia that is confirmed by chest radiography in the absence of complicating clinical or radiographic features
32. Performing imaging studies, rather than a high-sensitivity D-dimer measurement, as the initial diagnostic test in patients with low pretest probability of venous thromboembolism
33. Measuring D-dimer rather than performing appropriate diagnostic imaging (extremity ultrasonography, CT angiography, or ventilation–perfusion scintigraphy), in patients with intermediate or high probability of venous thromboembolism
34. Performing follow-up imaging studies for incidentally discovered pulmonary nodules 4 mm in low-risk individuals
35. Monitoring patients with asthma or chronic obstructive pulmonary disease by using full pulmonary function testing that includes lung volumes and diffusing capacity, rather than spirometry alone (or peak expiratory flow rate monitoring in asthma)
36. Performing an antinuclear antibody test in patients with nonspecific symptoms, such as fatigue and myalgia, or in patients with fibromyalgia
37. Screening for chronic obstructive pulmonary disease with spirometry in individuals without respiratory symptoms

PS. Salut i crisi a Grècia. Explicat al blog de Liaropoulos. Algú creu que Grècia pot pagar un interès del 34% del bo a 10 anys? Tothom sap que això és qüestió de dies però mira cap un altre costat.

PS. Sobre el tema de falsificació de medicaments, documents de la OMS

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