Medical Check-up RCTs: 250,000 and Counting

The number of people in trials of routine check-ups is now over a quarter of a million according to the most recent systematic review of randomised trials from Cochrane.[1] Still, the result remains null. If early diagnosis is so important, then the question is why? The argument often given is that these trials in high-income countries take place against a backdrop of well-developed primary care services. Any marginal gains are therefore very small and could be outweighed by marginal losses due to over investigation.

— Richard Lilford, CLAHRC WM Director

Reference:

1. Krogsbøll LT, Jørgensen K, Gøtzsche PC. General health checks for reducing morbidity and mortality from disease. Cochrane Data Syst Rev. 2019; CD009009.

More on Facilitated Self-Help in Health Care

News Blog readers know that I think General Practice should be re-engineered – wall-to-wall, ten minute encounters are satisfying to neither provider nor consumer of primary health care.[1] The same applies to follow-up visits in secondary care. My argument has recently been endorsed by Asch and colleagues in the New England Journal of Medicine.[2] They argue powerfully for “Facilitated Self-Service”, mimicking other industries, such as travel and fast food. The idea is that people receive standard, ‘algorithmic’ care online (by means of a ‘bot’). Then, if more support or advice is required, the service user accesses a physician’s assistant or nurse, keeping the most highly trained and paid workers (i.e. doctors) for where further escalation is required. These consultations can be more widely spaced because the less cognitively demanding work has been done by others. Barriers to such a system are more social than technical. The authors argue that fee for service payment, regulation and lack of research evidence are barriers to overcome. Our CLAHRC hosts projects under development on mHealth (at home and abroad) and online consultation.

— Richard Lilford, CLAHRC WM Director

References:

1. Lilford RJ. What is a GP For? – The End of the Fixed Consultation Period? NIHR CLAHRC West Midlands News Blog. 1 July 2016.
2. Asch DA, Nicholson S, Berger ML. Toward Facilitated Self-Service in Health Care. N Engl J Med. 2019; 380: 1891-3.

Quality of Care on Removal of Financial Incentives in General Practices

Minchin, et al. report on the use of interrupted time series analyses of electronic medical records to track the effect of removal of financial incentives on provider behaviour.[1] Incentives were withdrawn for 12 quality of care indicators in 2014, while they were retained for six indicators.

The results showed a sharp and almost immediate fall in adherence to the 12 indicators for which the incentive was withdrawn. There was no such drop in performance for the six indicators that were retained.

Many of the measurements of adherence were based on clinician entry into the electronics records to confirm compliance. For example, to confirm that advice on disease prevention had been given. It is therefore possible that clinicians continued to adhere to the tenets of good practice after withdrawal of the incentive, while simply omitting to record this detail in the electronic notes. However, not all measurements were dependent on active clinical entry – for example, the electronic record is populated automatically with blood test results. There was a fall in adherence to previously incentivised indicators, such as blood tests, where physician entry was bypassed, as well as on those that required physician entry. However, the fall in compliance with practice standards that did not depend on physician entry was not as great as the fall in compliance with indicators that depend on physician entry.

The results reported here are broadly in-line with the literature; removal of financial incentives for clinical care standards is generally followed by a decline in performance.

What does this mean for the use of performance measures? One must assume that they cannot be retained in perpetuity; at some point the world must move on, even if only to implement a further set of performance measures.  But my overarching impression is reconfirmed – the use of incentives, measurements and targets is of limited value. In the last analysis, the only way to bring about a sustained, lasting and self-perpetuating improvement in care, is by winning the hearts and minds of clinicians. It is important to kindle a set of high rectitude values, and it is important to select individuals with the right characteristics, i.e. highly principled people with a deep sense of altruism. This is, I am afraid, an ultra-long-term solution – a person’s attitude starts on mother’s knee and is reinforced or supressed by the totality of life experience. Inspiring teachers at medical school and good role models throughout life are critical. That is one reason that I continue to argue that medical ethics and, so-called, ‘communication skills’ should be taught by doctors and not farmed out to philosophers and psychologists.[2] When I was a clinical professor these valuable colleagues taught me, but I taught the students.

— Richard Lilford, CLAHRC WM Director

References:

1. Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of Care in the United Kingdom after Removal of Financial Incentives. N Engl J Med. 2018; 379: 948-57.
2. Lilford RJ. Doctor-Patient Communication in the NHS. NIHR CLAHRC West Midlands News Blog. 24 March 2017.

What is a GP for? – The End of the Fixed Consultation Period?

General Practitioners throughout the UK provide ten-minute consultation slots by default. An increasing portion of patients are seen for chronic disease and increasingly routine consultation are carried out by practice nurses. Telephone consultations are routine in many practices. The idea is that the GP should see the more complex cases. In theory this skill substitution should liberate time allowing GPs to provide larger default slots to patients. However, this has not happened, likely because demand has increased. Given that a further expansion in the GP cadre is not going to happen any time soon, should this state of affairs be accepted? It seems to me that the status quo cannot be endured – at least not without concerted effort to change it.

Consider first the patient. Can the needs of the patient really be met in such a short consultation unless they are very straightforward? And if they are straightforward, then is a highly trained and expensive professional needed? Dealing with depression, managing refractory blood pressure in a diabetic patient who is also complaining of a sore foot, counselling a patient who is considering whether or not to have a third round of chemotherapy – these are not ten minute tasks, but they are the stuff of primary care.

If you cannot provide compassionate care in five minutes, then how can you make a diagnosis? You need to record the symptoms, ask the patient to undress, elicit signs, and think about what it all means. Twenty-two percent of cancers present as emergencies,[1] and many of these patients have been seen by GPs before presentation.[2]

And what about the provider? I am consumer-orientated by philosophy, but at some point the provider interest becomes the consumer interest. Imagine consulting all day long, five days a week, for 45 years, at six patients per hour! Contrast that with an “old-fashioned” doctor; deliver a baby, consult in rooms, set a fracture, few more consultations, home visits.

Back in the 1950s the great Michael Balint spotted the problem. He advocated fewer consultations in greater detail for non-psychotic mental illness.[3] [4] So the idea is not new, and the challenge now is to find a way to make best use of advanced medical skills. Lots of things that seemed inviolate have been changed by human agency – the closing of the great mental asylums to be replaced by community care, for example. So let’s model how the service could look based on real patient lists. Then let’s simulate different methods to change the pattern of care, invoking plentiful skill substitution and perhaps greater reliance on technology and self-help. Then we could pilot it and finally roll it out, seeking buy-in from professional bodies. In fact, reverse that – let the professional bodies make the running while researchers in organisations such as CLAHRCs provide scientific ballast.

— Richard Lilford, CLAHRC WM Director

Reference:

1. National Cancer Intelligence Network. Routes to Diagnosis 2006-13. 2015.
2. Kidney E, Berkman L, Macherianakis A, et al. Preliminary results of a feasibility study of the use of information technology for identification of suspected colorectal cancer in primary care: the CREDIBLE study. Br J Cancer. 2015; 112(s1): s70-6.
3. Balint M. The Doctor, his Patient, and the Illness. Lancet. 1955; 265(6866): 683-8.
4. Balint M. The Doctor, his Patient, and the Illness. 2^nd Edinburgh: Churchill Livingstone, 2000.

An Argument to Give Family Physicians / GPs a Larger Role in Hospital Care

This article in the New England Journal of Medicine suggests a larger role for family physicians / GPs in hospital care.[1] It suggests that they should do rotations in which they work on the hospital staff. Alternatively, they should join ward rounds or visit patients in hospital. The suggested advantages are two-fold. Firstly, family doctors could influence care (for the better!) by advising hospital staff. Secondly, this contact would facilitate a smooth transition to the community after discharge. Aware of time constraints, they suggest virtual visits to the hospital through teleconferencing. The CLAHRC WM Director remains sceptical. Such an expanded hospital role for family doctors will be time-consuming even with teleconferencing, and the opportunity costs are not considered in the article.

— Richard Lilford, CLAHRC WM Director

Reference:

1. Goroll AH, & Hunt DP. Bridging the Hospitalist­–Primary Care Divide through Collaborative Care. N Engl J Med. 2015; 372(4): 308-9.