October 06, 2020
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Experts focus on most important recommendations to scale back care for chronic conditions

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.”

Doctor consulting with patient
In a review that appeared in JAMA Internal Medicine, authors provided 37 “high-priority deintensification recommendations” in a variety of specialties, including cardiology, endocrinology and pain management. Photo source: Adobe

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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