Last partial update: July 2019 - Please read disclaimer before proceeding

 

Modern medicine in Australia

Australia has a high standard of health care compared to the rest of the world, as would be expected from our relative wealth. About 30% of health care occurs in hospital, which is most involved in looking after illness, and the other 70% occurs in the community.

Hospital care - How good is it?

About 60% of hospital care is done well and follows accepted standards based on evidence of benefit. About 30% of care provides no benefit but does not cause harm (i.e. wasted time and money), including care that is not needed but done anyway, duplication of tests and unnecessary administration. Finally, about 10% of care does result in harm to patients. These figures are similar to those in other developed copuntries. Fortunately, much of this care that causes harm is preventable.

A key way of reducing waste and harm is making the population more aware of what is appropriate treatment and what are likely problems associated with their conditions so that they can interact better with their health professional and in turn get better care.

As the population ages and more people have chronic medical problems these issues are going to become even more important. Already about 13% of our population is over 65 years of age; 3.8 million Australians.

 

Is modern medicine finding too much disease? - What is normal and what is disease?

Not uncommonly, when asked the question ‘How do you feel?’, many people would probably not answer 'really well'. Most of us have symptoms of some sort much of the time, such as tiredness, headache, muscle aches etc and much of the time these symptoms just go away by themselves. They are part of our normal lives and do not indicate illness.

 

Similarly, when looking closely at the bodies of well people, doctors can sometimes find things that look abnormal but in fact will not cause us problems at all or go away completely and, as medicine advances, finding such inconsequential abnormalities is happening with increasing frequency.  Similar problems occur when doctors change the classification of what is normal and what is not with regard to a particular illness. (For example, lowering the normal level of cholesterol.)

 

All this has the potential for labeling well people as being sick and inflicting on them unnecessary worry and unnecessary investigations and treatments. It is important for people, as health consumers, to be able to recognise when such practices are occurring and to judge whether their implementation provides a health benefit. There is often no right or wrong answer; it is a matter of choice.

 

Here are some of the important ways this process can occur.

  1. Finding disease that will cause no harm: An example is screening for early cancers which, as well as finding lesions that may kill us if not treated, unavoidably also finds some early cancers that would never have caused problems. Commonly both end up being treated.
  2. Changing disease definitions: An example is blood pressure. Reducing the level at which blood pressure is classified as being high increases the number of people with high blood pressure. This process can also occur in mental illnesses such as depression, where the borderline between abnormal and normal is often very uncertain.
  3. Creating new diseases. An example of this phenomenon is attention deficit hyperactivity disorder (ADHD). ADHD did not exist as an illness a few decades ago. Now many children are diagnosed with the disorder; many justifiably but there is much debate about whether this condition is being over-diagnosed and over-treated.
  4. Classifying natural life events as illnesses. This process can have significant benefits; for example the careful medical management of pregnancy has saved many lives. However, in other areas such as ageing and menopause, the advantages of classifying them as illnesses and implementing treatment are less obvious. For example, the use of HRT in treating menopause symptoms and the use of drugs to increase the libido and sexual performance of an aging population have debatable benefits.
  5. Defensive medicine: Fear of missing a problem (and subsequent possibility of litigation) sometimes means that health professionals order additional tests that end up finding problems that would not have causesd any illness. Medicine is inherently uncertain but unfortunately people expect perfection from their health professionals.

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Preventing adverse events associated with medical investigations and treatments

Almost all doctors and other health workers practice their profession with the aim of making people better and they are continually getting better at doing this. While human involvement means that it will never be possible to stop all medical errors, medical practice today is becoming increasingly focused on finding the cause of these errors and introducing programs to minimise them. All major hospitals have systems in place to review all ‘adverse events’ and plan strategies to avoid them in the future. There are also external organisations carrying out similar reviews e.g. the Medication Safety Breakthrough Collaborative.

 

Unfortunately, although Australia has one of the highest standards of medical care and well trained, competent health professionals, adverse events (the medical term for errors) are still common; though no more common than in other western countries.

 

It is thought that about 10 per cent of hospital stays in Australia are associated with an ‘adverse event’ due to medical treatments. While most of these are minor and result in no long term problem, about one fifth are more serious. Most of these are due to complications of treatments or adverse drug reactions. Errors obviously occur outside hospital as well.

 

Sources of error are quite diverse and include the following.

While it is not possible for individuals in the community to influence all of these adverse events, there are numerous things that people can do to prevent these adverse events happening to them. Here are some suggestions.

 

 

 

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1. Stay healthy

This may seem obvious, but attention to a healthy lifestyle and good use of preventative health strategies, such as cancer screening, can prevent or postpone about 40 per cent of illness in the general population. Remember that adverse events can only occur as a consequence of a medical intervention or treatment and the risk of adverse reactions is to some extent proportional to the amount of interventions / treatments received.

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2.      Get the best medical care possible

This is not easy but addressing these important issues will help.

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3. Don’t overuse medical facilities.

One of the unfortunate consequences of increased litigation against health professionals is that it is creating a culture of defensive medicine. In order to reduce the risk of being sued, doctors are doing more investigations etc than they used to and this creates problems for patients, as follows.

It is not easy to avoid this situation as it is now common practice. However, patients can avoid having investigations for which there is little evidence of benefit, such as total body scanning.

 

Unhelpful scans / X-rays

 

While most scans are ordered for good reasons, some are not or are interpreted incorrectly. This can lead to unnecessary treatment. MRI scans of the back, the knee and the hip are common culpits. Finding abnormalities in these scans is very common in people with no symptoms. For example, in 30 year old people with no back pain, a disc bulge can be found in about 30%; and this goes up to 80% in 80 year olds. Similarly, knee abnormalities such as meniscal tears and cartliage damage are common findings amongst people with no knee symptoms.

 

This means that finding an abnormality in a scan does not mean that that abnormality is causing the problem. Finding a good GP who is judicious in ordering scans and thoughtful regarding the significance of any abnormalities found is very important in avoiding unnecessary treatment and the cost and potential harm this treatment can cause.

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4.  Use medication wisely

a. Avoid adverse events associated with medication.

Medications are a form of treatment and are usually prescribed because there is good evidence that the likely benefits are very much greater that the risks (i.e. side effects) involved with taking the drug. However, side effects and errors in administration are not uncommon and, importantly, are mostly preventable. This is an area where patients really can make a big difference and it is an area where big differences need to be made. Research suggests that about 10 per cent of patients attending their GP have had an adverse drug event in the past six months and half of these are in the moderate or severe category. The Australian Council for Safety and Quality in Health Care says that that adverse medication events account for 80,000 extra hospitalisations and cost the health system $350 million a year. There are several groups of people who are at greater risk of adverse reactions to medications. These include people who:

  • are taking numerous different medications, especially five or more
  • are taking more than 12 doses of medication a day
  • have had their medications changed recently
  • have more than one doctor prescribing medicines
  • have literacy or language difficulties, poor hand coordination, impaired sight, confusion or dementia or some other condition that makes it hard to remember what they've taken and when.

Many errors associated with medications are due to confusion regarding different tablets. This occurs for several reasons.

  • There are different names for the same drug. Each drug has a proper name that is the name doctors often use. However, commonly there are several companies who distribute each drug and they will each have their own brand name and this is the name on the packaging. Different doctors prescribe different brands of a drug and sometimes the dispensing pharmacist substitutes a different brand if it does not have the one prescribed or if another brand is cheaper than the one prescribed. Thus, it is easy to see how different brands of the same drug can find their way to a particular patient.
  • Quite often there are several strengths of the same drug available. Changing the dose of medication is often necessary and thus several doses of the same medication may find their way home. This will be an even bigger problem if the two medications have different brand names.
  • Patients continue to take a medication after they have been taken off it.

From the above it is easy to see how medication errors can occur. The best way to stop such errors is to do the following.

  • Review medication regularly (with a doctor): Anyone who is on medication should have it reviewed regularly by their doctor. The appropriate time to do this is when prescriptions repeats run out, although many people with chronic / more serious problems will need review before this. Repeats are usually given to cover the time a doctor feels it is safe to continue taking the medication without review. Getting further prescriptions without seeing a doctor is risky medicine. When patients come in to see their doctor for review, they should bring in the medications they are taking so that they can checked. This will also enable the doctor to check which brand has been dispensed.
  • Keep a copy of medications at hand always: This will mean the correct medications can be prescribed when away from home and is also a great help to doctors in an emergency treatment situation. Medication forms (called a ‘Medi-list’) are available from pharmacists or a list can just be written out. It is obviously important to always keep the list up-to-date.
  • Patient and doctor relationship: If possible, it is always best to attend the same GP practice so that personal records are available to the treating doctor. As always in medicine, it takes time to do a task properly and this is especially the case when a new medication is being prescribed. When choosing a GP, a prime consideration should be finding a practitioner who is prepared to give provide this time. (This may mean that the consultation is slightly more expensive but the potential health costs will usually be considerably greater if inadequate time is appropriated to this consultation.) From the patient’s perspective, it is important to ask questions when needed understand what has been said or would like further information.
  • Supervise medication dispensing in the patients unable to do this task safely: Some people, especially the elderly, are not capable of adequately supervising their medication and, to avoid ‘adverse events’, it is important that a friend or relative becomes responsible for this important part of their medical care. There are dispensing systems available from pharmacists to help with this task called ‘dossette boxes’. These boxes have several compartments for each day of the week that enable a week’s supply of tablets to be sorted out in advance. This can be very helpful for people with early memory loss but care needs to be taken in selecting who such a device is appropriate for. Likewise, young children should not be responsible for their medication.
  • Keep medications in their original containers and do not remove the label: This will help ensure the correct dose of the correct medicine is being taken. The exception to this rule is the use of ‘dossette boxes’ for people who suffer from memory loss.
  • Prevent child access to medicines: The poisoning of a child by prescription medicine is a very traumatic family event and is almost always preventable by keeping medicines in a locked cabinet out of the reach of children. Similarly, medications carried in handbags, travel cases etc need to be kept out of the reach of children. Ask a pharmacist to put medicines in child-proof containers.
  • Throw out old medication: Any medication that is not currently being taken should be thrown out. Keeping old medications is confusing and dangerous.
  • Home Medication Review Scheme: This is a government funded scheme which allows a GP to organise a home visit by a pharmacist to a person who is likely to be at risk of having an ‘adverse drug event’. Talk to a GP.
  • Side effects / adverse reactions: Concerns about an adverse reaction to a drug should be discussed with a doctor; preferably the one who prescribed the medication.  Do not just stop the drug as this can be dangerous and may cause more harm than the side effect being experienced. When necessary, most doctors will be happy to discuss an acute problem on the phone, give appropriate advice, and then make a follow up appointment.
  • Medications and hospital admissions: This is a very common time for medication errors to occur. Many people are discharged from hospital on medications that are different in type or in name from those they were taking before admission. It is really important to go through medications with a nurse or doctor before leaving hospital and to compare them with the medications being taken before admission. This requires an up-to-date list of ‘pre-admission’ medications being available prior to discharge. This process will allow patients to:
    • Become knowledgeable about new medications, including:
      • the required dose (and whether this will need to change later on),
      • likely side effects of the medications
      • how long the medication needs to be taken
    • Stop duplication of medications.
      • When the hospital dispenses a discharge medication that is the same as one being taken prior to admission, it may provide a different brand or use the drug’s proper name. As stated above, this can be a source of confusion.
      • There are often several different types of drug in the same drug group. The hospital doctor may change the type of drug being taken and if the patient continues taking their old medication, he or she will be taking two similar drugs.

It is also very important to see a general practitioner early after discharge so that medications can be reviewed and up dated in practice medical records. It will also provide an opportunity to ask about problems / side effects that may be present. At this visit it is vital to bring the hospital discharge summary, as it will contain a list of discharge medications.  (Actual medications should also be taken.)

Finally, to help cut costs, hospitals will often only give patients being discharged enough medication for the first week or so. In most cases this does not mean that the medication should be stopped when it runs out. Most medications will need to be continued for a much longer period. What it does mean is patients should see their GP BEFORE medications run out to check which medications need to be continued. (Hopefully the hospital staff will have already conveyed this information.)

Knowing more about a particular medication

The National Prescribing Service's Medicines Line is a service in Australia that provides independent information about prescription medicines, over-the-counter medicines and complementary medicines, including herbal and natural remedies. The service is confidential. Enquires are answered by a qualified pharmacist who will be happy to answer any question, including those relating to dosage, side effects, storage issues etc.

Ph:  1300 888 763 (from 9 am to 6 pm; East Coast time)

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b. Safe use of medications in older people

Medication use by older Australians causes much illness with between 85,000 and 110,000 Australians over 65 are admitted to hospital each year because of adverse reactions to prescribed drugs. Problems are related to both the number and kind of drugs taken. (In 2019 about one million Australians take five or more medications>)

Why is care needed in prescribing for the elderly? Here are some reasons?

  • A recent study suggested that in 2005 over 400,000 Australians over the age of 70 years were prescribed a drug that is potentially inappropriate for use elderly patients.
  • There is little evidence about the effects of medication in older people, who represent only about 3% of participants in well conducted studies of medications. Unfortunately extrapolating results to older people does not always give an accurate picture of likely benefits and adverse reactions.

  • Generally speaking, adverse reactions are more significant in elderly people, who are four times more likely to be admitted to hospital because of an adverse drug reaction. It is thought that about half of drug reactions that occur in older people could be prevented by better prescribing.

  • Adverse drug reactions are less likely to be reported on in older people and are often misdiagnosed as a medical condition. Medications should always be suspected as the underlying cause of falls and confusion in older people and should be thought of as a possible cause in almost all new illness in older people. (Medications are the cause of about 10% of cases of chronic confusion and dementia.)

  • Increased risk of toxicity is a problem in older people, occurring mainly due to kidney and liver abnormalities that reduce the ability of the body to metabolise or excrete the medication.

  • The prescription of five or more medications (termed polypharmacy) is common in older people; the incidence is about 20% to 40%. (While in some cases polypharmacy is necessary, the main risk factor is the prescribing doctor.) Polypharmacy is associated with several problems including:
    • 3 to 4 times the incidence of adverse reactions (up to 80% of people on 6 or more medications)
    • a doubling of the risk of falls
    • increased incidence of prescription error (incidence to 35% or more)
    • a higher incidence of side effects. (An addition problem here is that side effect of a medication (e.g. constipation) can seen as a new condition rather than a side effect and another drug is added to treat this side effect when altering the drug causing the problem might have been a better option.)

What can be done to make medication use safer in older people?

1. Make sure that you keep an up to date list of all the medications you are taking (with doses)

2. Make changes gradually and monitor the patient carefully when changes are being mad:

  • Try to only change one medication at a time
  • Start with low doses (often less than half the normal adult dose is appropriate) and increase the dose gradually if required.
  • Patients should report any adverse reactions to their medication promptly

3. Simplify medication by when ever possible:

  • avoiding polypharmacy
  • using medications that require single daily doses where possible

4. Where polypharmacy already exists, doctors can try to reduce the number of medications being taken.Where polypharmacy exists, it is often worth considering reducing the number of medications being taken. Several studies have shown that this can be done without consequence in appropriate situations. However, this depends on the medication and the situation and It is VERY IMPORTANT that this is coordinated by the person's doctor. Stopping some medications can be dangerous and it is not something a person should do without consulting their doctor. Gradually reducing the dose rather that abrupt cessation can help reduce the likelihood of problems and make patients (and doctors) less worried about possible consequences.

5. Avoiding where ever possible medications that are more likely to adversely affect older people
There are numerous medications that are likely to cause problems when given to elderly patients. The main adverse reactions these medications cause are:

  • confusion and drowsiness, which cause difficult behaviour and increase the risk of falls. These effects are mainly caused be drugs acting on the brain (sedatives, medications for depression, antipsychotics)
  • a postural drop in blood pressure which causes dizziness and thus an increased likelihood of falls
  • exacerbation of chronic kidney failure (Mild to moderate chronic kidney failure is common in elderly people, especially women, and often causes no symptoms and thus remains undiagnosed.) Arthritis medications can cause this problem.
  • nausea and vomiting
  • haemorrhage due to the use of anticoagulants, such as aspirin and warfarin, and arthritis medications

Important groups of medication that cause the above and should be used warily in elderly people include:

  • Medication for treating depression, including:
    • Tricyclic antidepressants
    • MAO inhibitors
    • SSRIs (Selective seretonin release inhibitors)
  • Sedatives used for anxiety and as sleeping tablets, mainly benzodiazepines. Sleeping tablets are BEST AVOIDED as they alter normal sleeping patterns. Always try non-medication treatments first. (If sleeping tablets must be used, do so for no more than 2 weeks.)
Click here to access section 'Sleep'
  • Antipsychotic medications: These are used in older patients to manage difficult behaviour, usually associated with dementia. Research has shown them to be of questionable benefit for this use and they should be avoided where possible. (It is important to look for other causes of the behaviour such as pain , infection and constipation and to help disorientation by making the person's surrounding environment as reassuring and familiar as possible; see boxed section below.
  • Sedating anti-histamines
  • Non-steroidal anti-inflammatory drugs, which are mainly used for arthritis and pain killers.
  • Some blood pressure medications
 

Methods of reducing difficult behaviour resulting from disorientation in older people without using medication

  • Surround the person with personal belongings, familiar objects, pictures of family etc
  • Provide clocks and calendars
  • Provide TV, radio etc for relaxation
  • keep in contact with old friends and maintain usual activities
  • if required, ensure the person has correct glasses and uses them
  • check hearing and provide hearing aids if required
  • check dentition
  • ensure they are comfortable
    • warm, clean and well fed
    • as pain free as possible
    • room is well lit and noise levels are not excessive
  • consider providing a pet for company

Researchers in the USA have established criteria for determining which medications are 'Potentially Inappropriate Medications for the Elderly; the 'Beers' criteria.

A list of medications produced in 2003 can be accessed from the following web site. (Some of these are not available in Australia.) http://www.dcri.duke.edu/ccge/curtis/beers.html

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c. Gaining maximum benefit from medications

Many drugs have been shown to provide very significant benefit in helping prevent a variety of diseases, especially heart attacks. Some important examples include:

  • The use of ACE inhibitor medications (a group of medications often used to treat blood pressure) in people who have a history of vascular disease*.
  • The use of statin medications to lower cholesterol in people with a history of vascular disease or at significantly increased risk of future vascular disease.
  • Blood pressure medication in people with diabetes.
  • Beta-blocker medications in most patients with heart failure.

(The benefits gained from the medications mentioned above can be as high as a 20% to 35% reduction in the incidence of future heart attacks, stokes and death!! Please note, these medications are not suitable for all patients in these groups. All patients need to seek advice from their medical practitioners regarding appropriate medications for their medical problems.)

 

However, many people using these medications (often as many as 50%) do not gain such substantial benefits because they are not using the most appropriate dose.

 

There are numerous reasons for this, with the following being the most important.

  • People in the community are not supervised as well as those being observed in 'drug studies' and thus their treatment may be less well managed. This is something patients and doctor can work on and patients need to develop a plan to manage their medication with their doctor so that optimum outcomes can be achieved.  For example, patients attempting to lower their total cholesterol to less than 4.0mmol/L should continue seeing their doctor and altering their medication regularly until this level is reached and not just assume that the first dose tried will get them there. They then need to monitor their cholesterol level regularly to ensure that this level is maintained. (Having said this, it is not always possible to obtain an optimum outcome.)
  • The side effects of a medication may be significant enough to make patients want to stop that medication. However, there are often alternatives that a doctor can suggest. Do not just stop it.
  • Most of the benefits of these drugs are in the future and they will not actually make patients feel better while taking them. It is therefore important to remember that future benefits, such as preventing heart attacks, are very real and worthwhile pursuing.
  • Discharge medications from hospital often need adjustment soon after returning home and this is sometimes not done. It is important to see a doctor soon after discharge to sort out the best dose of medication. Also, often only a few days medication are given at discharge and a repeat prescription will need to be obtained. Do not assume medications no longer need to be taken once they have run out.

Remember that maximising benefit from a medication requires effort.

Reasons for non-compliance with long-term medical therapy

 

About 40 to 50 per cent of people who have been advised to take long-term medication therapy do not continue with this therapy for longer than 12 months, irrespective of the disease being treated. This non-compliance can adversely affect their health outcomes very significantly. The reasons for this are detailed below. Many relate to more time spent in patient education. This is the responsibility of both the doctor AND the patient.

Reason

Solution
Where treatment is preventative in nature, the absence of symptoms means there is no immediate advantage gained. More time spent in patient education.
Lack of knowledge about disease
Denial of illness
Disagreement about the need for treatment with medication Achieve compromise between doctor and patient.
Illness affecting attitude to medication e.g. mental illness, especially depression and dementia Awareness by GP and other family members
Lack of support from other family members Counselling by GP
Complicated / inconvenient administration due to multiple medications, frequent dosages

Help from family

Change in medication administration
Medication side effects Change medication or change dosage

Cost of medication

Try cheaper option.

Cost of follow up

Discuss issue with patient

 

 

Further information


Australian Prescriber is an independent journal and website that provides information about drugs and medicines for health professionals.
http://www.nps.org.au/publications/health-professional/australian-prescriber

The National Prescribing Service Ltd
A non-profit, Federal Government funded organisation which is consumer-focused and provides information relating to medicine safety and guides to specific prescription medicines and some non-prescription medicines.
http://www.nps.org.au

 

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Accessing competent medical care

 

In Australia, medical advice is available from a variety of health professionals.  Many of these practitioners provide conflicting advice regarding diagnosis and treatment, so deciding on ‘the correct choice’ is not always an easy task.

 

It is, however, a very important task. Upbringing, past experiences of family and friends, and the media are just some of the influences that help people decide on their medical direction.

 

Hopefully the problem of doubting the medical advice being received will often occur. However, when people are faced with this problem or they just wish to know more, they will need to stand back and accurately assess the medical advice and treatment being offered. To do this, they require information about some basic issues, as outlined below.

Can the practitioner provide quality treatment that works?

The practitioner’s field of expertise needs to be one that provides quality care that works. The best way to identify fields providing quality care is to ask the following questions.

 

Such well-recognised fields include traditional medical practice, physiotherapy, dental surgery, occupational therapy, optometrists, social workers, dietitians, psychologists etc.

 

If the field is less well-recognised, it does not mean that it cannot contribute to quality health care in the community. However, it does mean that their profession and the products they sell / prescribe are less well regulated, both by government bodies and by the profession itself which may affect educational standards. Also, the knowledge base for both professional education and treatments may be less well researched, leading to treatments based on less accurate information and a greater variety in the treatment practices offered by practitioners in the field. This can lead to inappropriate treatments and it means people need to be more careful in assessing the accuracy of advice given.

 

It is important to ensure that the person providing the information is adequately trained in their field. Where did they obtain their medical education?

Conflict of interest.

Also worth considering is whether the provider of medical care has a conflict of interest in the advice or treatment being given? While all providers of medical care make their living from seeing patients, some can obtain additional financial benefits. For example, they may also supply medications and other treatments for which they receive payments. This is one reason it is illegal for most doctors to sell medications. (Some remote country doctors can dispense medicines.) Also they may receive benefits for referring patients for other forms of care or treatment. For example, they may be financially associated with practitioners that they refer to. Some practitioners may have a financial interest in medical facilities, such as hospitals.

 

Such conflicts do not mean that the care delivered will be less than optimum. They just mean that there are interests other than the patient’s best health operating and extra care needs to be taken.

A reasonable fee for the consultation

As stated above, all health professionals earn a living by seeing patients. They have generally studied for numerous years to attain their qualifications and are entitled to a reasonable financial reward for their labours. They also have to cover the considerable expenses of running their practice.

 

For these reasons, patients should be suspicious of any practitioner who does not charge for their consultation time. It means that either they are very generous or they aim to make their money from the treatments or medications they advise or sell.

 

The problem with paying for the treatment and not the consultation is that to avoid going broke, the practitioner have to treat the patient for something whether they need it or not. (If they don’t, it means that the next patient is kindly paying for the treatment; a highly unlikely event!) Also, if the practitioner wishes to continue receiving remuneration, the patient will need to continue receiving treatment that is perhaps unnecessary.

What evidence is there that the treatment is beneficial?

Patients who are unsure about the advice they are receiving and wish to know more need to ask for information about the advised treatment. This information then needs to be assessed as to its true worth. Asking the following questions will help ascertain this.

There is nothing more upsetting to a practitioner than being unable to help a patient. When this occurs, it is natural for the patient to seek other opinions, often from practitioners working in different medical fields. Please be wary of practitioners offering cures for difficult problems. Ask for the evidence! There is no point wasting time, energy and money in the hope that something might happen.

 

“If a lot of cures are suggested for a disease, it means the disease is incurable.”

                                                                                   Anton Chekhov (1860-1904)

  

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What medical information can be relied on? - Evidenced-based medicine

 

Unfortunately much of the way all types of health care was practiced everywhere in the world was not founded on good evidence that it is of benefit to the patient. Up until about 30 years ago, with all the best intentions, medical practitioners used logic, personal clinical experience (their own and that of their educators and colleagues), and poorly designed studies to fashion the way medicine was practised. In some branches of health care this unfortunately remains the case.

 

Luckily, in recent years, there has been a strong move in traditional medicine to base all treatments on well-founded medical evidence. This strategy for medical care is termed ‘evidence based medicine’. (See below.) Not surprisingly, several well-conducted studies have shown that doctors who strive to practice evidenced-based medicine where ever possible provide better outcomes for patients.

 

The fact that there is more money for research in areas of traditional medicine gives it a research advantage over some other areas of health care. However, the onus is on all practitioners to justify their treatments. Treatments should not be based on poorly conducted research or assumptions / unproven beliefs. Such beliefs can be long held and may sound reasonable. However, if they haven’t been proven, be careful. Recommendations and reatments based on the unsubstanciated, past experience of practitioners are not good enough in modern medicine. Remember, if in doubt about a treatment, ask more.

 

The best place to access medical information and advice that is based on quality evidence is 'The Cochrane Collaberation'. Information regarding a multitude of health topics can be gained from its consumer oriented site a: http://www.cochrane.org

How much good evidence is available for medical treatments and recommendations?

Unfortunately, only a relatively small number of medical treatments and recommendations are supported by very conclusive evidence. There are several reasons for this.

  1. Obtaining very good evidence to support a medical treatment or recommendation is not cheap. This means that a 'private enterprise' is only going to bother performing a trial if there are likely to be a significant financial gain and thus some potentially beneficial newer medications and procedures may not be promoted. It also means that the investigation of the benefits of medications, procedures and dietary advice that can not be patented is left to the ever-decreasing research budgets of universities etc.
  2. It is not possible to obtain very good evidence to support some medical recommendations due to the difficult nature of studying them. This is especially the case with dietary recommendations, which are thus often categorised in rather vague terms; such as being 'very likely', 'moderately likely' or 'unlikely' to be of benefit.
  3. Obtaining good evidence can take a great deal of time. For example, studying the effect of reducing childhood sun exposure on adult melanoma incidence takes decades.

Obtaining good evidence to support current medical recommendations and treatments (where this can be achieved) is progressing but will take time. Thus, a medical practitioner will not always be able to give a conclusive answer regarding the overall benefit of a particular recommendation or treatment being advised. While this is a problem whenever it occurs, the issue of being unable to provide good evidence to support a recommendation is very important issue when dealing with preventive health issues. This is because the people involved are generally not unwell and thus it is imperative that there is good evidence to show that there is a significant overall benefit to the community from a preventive health intervention and that people likely to be better off. This is the problem with recommending prostate cancer screening using the PSA test; it might help but we just do not know, yet.

Can we rely on the evidence from medical trials? - Reporting on studies is improving

One recent beneficial change regarding the reporting of trial results is that reputable medical journals are now only publishing trials results where the manner in which the results are to be reported has been clearly outlined before the trial commences. This prevents practice, which has occasionally occurred in the past, of only publishing favourable results. For example, the results of a study looking at the benefits of a new medication may be more favourable at six months than they are at one year and it would be very tempting for the company to just report on the six months results. In reputable journals, all results must be reported and published, favourable or not.

Reporting on medical trials etc in the media

The reporting of the latest medical breakthrough is common place in the media with cures for all manner of illnesses seeming to be found on a daily basis. It is very important to be aware that much of this reporting occurs on studies and research that is on its own inconclusive. The media is interested principally in selling a story and thus will report on almost any interesting medical topic. However, as the saying goes, 'one swallow does not make a summer', and even if the research reported on is well conducted and significant, before the medical community make changes to accepted advice and treatments, a body of accurate evidence needs to be accumulated to support the new finding.

 

The exception to this is where a study result shows potential harm may be being caused by a current recommendation or treatment. In this situation, action may be taken before further evidence is obtained. When worried about a health risk that is reported on in the media, make an appointment to discuss it with a doctor. And remember, if there is a real problem, it is likely to be commented on and acted on by Government health authorities.

 

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Evidence-based medicine

Most patients would expect that doctors advice was based on information that supported its benefits. Surprisingly, in the past this was commonly in not the case and treatments were based on the clinical experience of doctors or on evidence gained from research that was flawed.

 

Luckily, overe the past thirty years or so this has changed and most medical treatments are now based on sound medical research. Advic and treatments based on such research is termed evidenced-based medicine and there have benn several studies to show that doctors who strive to practice evidenced-based medicine where ever possible provide better outcomes for patients.

 

Below is some general information about how medical research is conducted and which type of research provides the most reliable information.

 

There are two basic ways that studies can provide evidence used to determine helpful treatments. They can either look prospectively (in the future) or that look retrospectively (in the past).

Prospective studies

The best type of evidence is gained by looking forward at what happens to participants in a study. Studies that do this are called prospective studies. The reason that these are better is that they can look at randomly selected normal populations, not populations that have been selected because they already have a particular disease and are thus 'not normal' with respect to the condition being studied. There are two types of prospective trials/studies.

Randomised controlled trials

These trials provide the best information. They randomly selected a group of subjects and divide them into controlled and uncontrolled groups. The uncontrolled group continues as before. The controlled group has one factor changed and the effect of this change on the two groups over a period is noted to see if there are significant differences. (For example, such a study could be designed to examine the effect of taking calcium supplements on bowel cancer.)

 

If the participants and the observers are unaware which group they are in, then the trial is called a double blind trial. (In our example, this might mean all participants were given similar tablets with only some containing calcium.) Double blind trials are best because, as the participants and observers do not know who is in each group, it is not possible for their behaviour to affect the outcome.

 

The problem with these studies are that they rely on participants performing the trial properly (in our example, they must take their tablets) and they are time consuming and thus expensive. Also, due to the expense involved, they are usually restricted in follow up time and if the time allowed is inadequate, it may mean that the effect being looked for has not had time to appear. (Obviously studies are designed with time frames that try to avoid this problem.)

Cohort (or longitudinal) studies

In these studies, a random group of individuals is selected and then observed at regular intervals for changes that might occur. Taking the calcium and bowel cancer example again, this type of study would randomly select a group and at regular intervals ask them about their calcium intake and any incidence of bowel cancer. Any causal relationship could then be assessed.

 

These studies are easier to do because the group is not being asked to do any specific task. They are also cheaper and easier to assess and thus follow-up can be over a much longer period.

 

However, interpreting the results is more difficult because there are many variables that might affect the outcome being investigated. In our example, the individuals who had high calcium intakes can be determined and then their incidence of bowel cancer is detected to see if it was lower. The problem with doing this is that the group selected may also have had a healthier diet rich in fruit and vegetables and it may have been this and not the increased calcium that caused the reduced bowel cancer. For this reason, these studies need to be carefully planned so that other known associated factors are also examined in the study and allowed for in the results.

Retrospective studies

Studies that look at a group of people with a particular medical condition, such as bowel cancer, and then try to work out factors that might have caused the problem are called retrospective studies.

 

Results from such studies are not as reliable as prospective studies. The reason for this is that they are not looking at a normal population. They are looking at a population that already has the problem being researched (such as bowel cancer). This can affect the findings of the study as it may turn out that the findings do not apply to a normal population.

Case-controlled studies

Case controlled studies look at a group of people with a specific problem (e.g. bowel cancer) and try to compare them with a similar population in the hope of finding the differences that caused them to develop the problem. In our example, both groups could be asked about their previous calcium intake and the findings compared. The problems with case controlled studies are that memories are not always accurate (and may be subject to bias) and numbers in the group with the problem are often small, making the findings less accurate.

Epidemiological studies

These studies look at the incidence of diseases and possible causes in population groups. From this information, it is possible to look for associations between diseases and possible suspected causes. For example, Japanese people have a high incidence of stomach cancer and also eat large amounts of charred food. From this it could be implied, but not proven, that eating large amounts of charred food causes stomach cancer. This is the least reliable type of evidence commonly presented.

 

Assessing all the available information about a topic

Usually there will be numerous sources of information about a particular topic. Some will obviously be better than others and some may give conflicting findings. All this information must be assessed in order to come to a conclusion and there will be some topics where the conclusion is obvious and others where it is less certain. For this reason, conclusions made from the analysis of evidence regarding a particular topic and advice based on these conclusions are graded according to the quality of the evidence assessed (a number) and the strength of the conclusion that can be reached from that evidence (a letter) as follows.

Quality of evidence

  1. Level I – Evidence gained from a review of all relevant randomized trials.
  2. Level II – Evidence gained from at least one properly designed randomized trial.
  3.  Level III – Evidence obtained from any of the following:
    • well designed pseudo randomized controlled trials
    • comparative studies with cohort trials, case-control study or interrupted time series with a control group
    • comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel control group
  4. Level IV – Evidence gained from case series, either post-test, or pre-test and post-test.
  5. Level V – Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Strength of recommendation

A – There is good evidence to support the recommendation

B – There is fair evidence to support the recommendation

C – There is poor evidence regarding including or excluding the recommendation

D - There is fair evidence against the recommendation

E - There is good evidence against the recommendation

 

Thus, a ‘IA’ recommendation indicates that the most accurate trials possible have provided very conclusive findings. A ‘VC’ recommendation is not much better than personal opinion.

 

Evidenced-based medicine resources

 

The Cochrane Collaberation: http://www.cochrane.org/.

This is probably the most comprehensive general resource for evidenced-based medical research and has sections aimed at providing information for both patients and medical practitioners.

 

 

Choosing Wisely Australia: http://www.choosingwisely.org.au/home

 

This is a web site dedicated to helping patients and health professionals choose tests and treatments that achieve the optimum balance between the benefits and harms they provide.

 

 

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