Lanzamiento de la campaña Choosing wisely Argentina: primeros pasos hacia la desimplementación de prácticas de bajo valor

En esta editorial, la autora aborda la problemática de las prácticas de bajo valor en la medicina contemporánea: aquellas intervenciones terapéuticas o diagnósticas carentes de respaldo científico, que aumentan la probabilidad de daños, generan desperdicio de recursos y amenazan la eficiencia del sistema de salud. En un contexto de preocupación global por el exceso médico y las consecuencias del sobreuso de intervenciones inefectivas, resalta la relevancia del concepto de prevención cuaternaria en la atención sanitaria, y señala la iniciativa internacional Choosing Wisely como una estrategia para identificar y revertir las prácticas de bajo valor, destacando la importancia del cambio cultural y la participación activa de los pacientes. Finalmente, la autora presenta el lanzamiento de Choosing Wisely Argentina, una colaboración entre asociaciones científicas locales con el compromiso de transformar la práctica médica en este país, priorizando el bienestar del paciente y adoptando un enfoque integral hacia la atención sanitaria

Excesivo rastreo de osteoporosis en mujeres menores de 65 años: estudio de corte transversal

Overuse of osteoporosis screening in women at low risk of fracture may lead to overdiagnosis, inappropriate treatment and medicalization. The objective of this work was to estimate the proportion of women aged 45 to 64 enrolled in a private health insurance plan in Buenos Aires undergoing hip dual-energy x-ray absorptiometry (DXA) in 2011 without meeting osteoporosis screening criteria. In this cross-sectional study, 4310 women of this age range that had undergone a hip DXA were identified. A randomly selected sub-group of 401 women was then assessed for the presence of risk factors for osteoporosis and complete data were retrieved for 178 women. Appropriate screening was defined by two criteria: 1) having a 10-year fracture risk higher than that of a 65-year old woman (estimated using the FRAX® tool); 2) having at least one risk factor for fracture. It was found that 86.5% of the women who underwent hip DXA did not exceed the minimum 10-year fracture risk threshold required for screening; 5.8% of them had osteoporosis and 61.0% osteopenia. According to the second criterion, 49.4% had no risk factors, 3.4% of these women had osteoporosis and 62.5% osteopenia. The results show that at least half the women screened did not meet osteoporosis screening criteria.El rastreo de osteoporosis en mujeres con bajo riesgo de fractura (sobreuso) puede conducir a sobrediagnóstico, tratamiento inapropiado y medicalización. El objetivo de este trabajo fue determinar la proporción de mujeres de 45 a 64 años afiliadas a un plan de medicina prepaga de Buenos Aires, Argentina, que realizaron al menos una densitometría ósea de cadera durante 2011 y no cumplían criterios para el rastreo. Se realizó un estudio observacional de corte transversal. Se identificaron 4.310 mujeres de este rango etario que se realizaron una densitometría ósea, entre las que se seleccionó una muestra aleatorizada de 401 mujeres y se obtuvieron datos completos para 178 mujeres. Para determinar si el rastreo era apropiado se utilizaron dos criterios: 1) tener un riesgo de fractura a 10 años mayor que una mujer de 65 años (regla FRAX®); 2) presentar al menos un factor de riesgo de fractura. Un 86,5% de las densitometrías óseas fueron realizadas en mujeres cuyo riesgo estimado por FRAX® no superaba el umbral mínimo recomendado, constatándose osteoporosis en el 5,8% y osteopenia en el 61,0%. En relación con el segundo criterio, el 49,4% no presentaba siquiera un factor de riesgo, documentándose osteoporosis en el 3,4%, y osteopenia en el 62,5%. Los resultados muestran que al menos la mitad de las mujeres no cumplía con los criterios de rastreo.

Sobreuso de mamografía para rastreo en un hospital académico de Buenos Aires

INTRODUCCIÓN: El rastreo de cáncer de mama en la población general asintomática no está recomendado en mujeres menores de 40 años y es controvertido en las de 40 a 49 años. El uso inadecuado de mamografía con fines de rastreo (sobreuso) y su consecuencia, el sobrediagnóstico, pueden conducir a tratamientos agresivos.OBJETIVO: Reportar la proporción de mamografías inapropiadamente realizadas en mujeres menores de 50 años afiliadas a un plan de salud de un proveedor de medicina prepaga.MÉTODOS: Se efectuó un estudio observacional de corte transversal. Se identificó a las mujeres de 18-39 y de 40-49 años afiliadas al plan de salud del Hospital Italiano de Buenos Aires que se habían realizado al menos una mamografía en 2012. Se revisaron las historias clínicas de 200 pacientes en cada grupo de edad para determinar si la mamografía había sido solicitada para rastreo de cáncer de mama. RESULTADOS: Durante 2012, 1533 mujeres de 18-39 años se realizaron una mamografía. En 96 de las 200 historias revisadas, esta prueba había sido solicitada con fines de rastreo (48%; IC 95%: 40,9-55,2%). Entre las mujeres de 40-49 años, 4432 tenían una mamografía efectuada ese año. Se revisaron 199 historias clínicas; en 105 casos, el estudio había sido solicitado con fines de rastreo (52,8%; IC 95%: 45,6-59,9%). No se realizó ningún diagnóstico de cáncer de mama como consecuencia de esta estrategia de rastreo.CONCLUSIONES: La alta proporción de sobreuso de mamografía para rastreo es especialmente preocupante entre las mujeres más jóvenes y revela la dificultad que los médicos pueden tener para adoptar las guías de práctica clínica más actualizadas.INTRODUCTION: Breast cancer screening in the general asymptomatic population is not recommended in women younger than 40 years old, and it is controversial among women aged 40 to 49 years. Overuse of screening mammography and its consequence, overdiagnosis, can lead to aggressive treatments. OBJECTIVE: To report the proportion of mammograms that were performed for breast cancer screening among women younger than 50 years old enrolled in a private Health Insurance Plan in Buenos Aires, Argentina. METHODS: A cross-sectional observational study was performed. Among women aged 18 to 39 and 40 to 49 years old enrolled in a private health plan (Hospital Italiano de Buenos Aires), those with a mammogram conducted in 2012 were identified. Of them, 200 in each age group were randomly selected. Their medical charts were reviewed to determine if the mammography had been performed for breast cancer screening purposes. RESULTS: During 2012, 1533 women aged 18 to 39 years old had a mammogram conducted. Of them, 200 charts were reviewed, 96 of which were determined to have a screening mammography (overuse proportion: 48%; 95% CI: 40.9-55.2%). Among women aged 40 to 49, 4 432 had a mammography performed during 2012. The charts of 199 of these women were reviewed. The mammogram had been conducted for screening purposes in 105 cases (overuse proportion: 52.8%; 95% CI: 45.6-59.9%). There was no diagnosis of breast cancer as a result of these screening mammograms. CONCLUSIONS: This high overuse of screening mammography is particularly concerning among the younger women and highlights the difficulty physicians may have to adopt the most updated guidelines.Fil: Salgado, Maria Victoria. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Kopitowski, Karin Silvana. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Hospital Italiano; ArgentinaFil: Barani, Mariela. Hospital Italiano; ArgentinaFil: Vietto, Valeria. Hospital Italiano; ArgentinaFil: Terrasa, Sergio Adrian. Hospital Italiano; Argentin

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

Background. Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions. Methods. An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved). Conclusions. Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.Centro de Endocrinología Experimental y Aplicada (CENEXA

Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review

OBJECTIVE: Overdiagnosis and overuse of healthcare services harm individuals, take resources that could be used to address underuse, and threaten the sustainability of health systems. These problems are attracting increasing attention in low-income and middle-income countries (LMICs). Unaware of any review of relevant evidence, we conducted a scoping review of the evidence around overdiagnosis and overuse of diagnostic and screening tests in LMICs. DESIGN: Scoping review. METHODS: We searched PubMed, Embase, PsycINFO, Global Index Medicus for relevant studies published until 24 May 2021, with no restrictions on date or language. We categorised included studies by major focus (overdiagnosis, overuse of tests, or both) and main themes (presence or estimates of extent; drivers; consequences and solutions). RESULTS: We identified 2763 unique records and included 162 articles reporting on 154 studies across 55 countries, involving over 2.8 million participants and/or requests for tests. Almost half the studies focused on overdiagnosis (70; 45.5%), one-third on overuse of tests (61; 39.6%) and one-fifth on both (23; 14.9%). Common overdiagnosed conditions included malaria (61; 39.6%) and thyroid cancer (25; 16.2%), estimated to be >70% in China. Overused tests included imaging (n=25 studies) such as CT and MRI; laboratory investigations (n=18) such as serological tests and tumour markers; and procedures (n=14) such as colonoscopy. Drivers included fear of conflict with patients and expanding disease definitions. Common consequences included unnecessary treatments such as antimalarials, and wasted resources, with costs of malaria overdiagnosis estimated at US$86 million in Sudan in 1 year alone. Only 9% of studies discussed solutions, which included addressing inappropriately lowered diagnostic thresholds and reforming test-ordering processes. CONCLUSIONS: Overdiagnosis and overuse of tests are widespread in LMICs and generate significant harm and waste. Better understanding of the problems and robust evaluation of solutions is needed, informed by a new global alliance of researchers and policy-makers

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

Background. Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions. Methods. An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved). Conclusions. Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.Centro de Endocrinología Experimental y Aplicada (CENEXA

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

Background. Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions. Methods. An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved). Conclusions. Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.Centro de Endocrinología Experimental y Aplicada (CENEXA

Excesivo rastreo de osteoporosis en mujeres menores de 65 años: estudio de corte transversal

Overuse of osteoporosis screening in women at low risk of fracture may lead to overdiagnosis, inappropriate treatment and medicalization. The objective of this work was to estimate the proportion of women aged 45 to 64 enrolled in a private health insurance plan in Buenos Aires undergoing hip dual-energy x-ray absorptiometry (DXA) in 2011 without meeting osteoporosis screening criteria. In this cross-sectional study, 4310 women of this age range that had undergone a hip DXA were identified. A randomly selected subgroup of 401 women was then assessed for the presence of risk factors for osteoporosis and complete data were retrieved for 178 women. Appropriate screening was defined by two criteria: 1) having a 10-year fracture risk higher than that of a 65-year old woman (estimated using the FRAX® tool); 2) having at least one risk factor for fracture. It was found that 86.5% of the women who underwent hip DXA did not exceed the minimum 10-year fracture risk threshold required for screening; 5.8% of them had osteoporosis and 61.0% osteopenia. According to the second criterion, 49.4% had no risk factors, 3.4% of these women had osteoporosis and 62.5% osteopenia. The results show that at least half the women screened did not meet osteoporosis screening criteria.El rastreo de osteoporosis en mujeres con bajo riesgo de fractura (sobreuso) puede conducir a sobrediagnóstico, tratamiento inapropiado y medicalización. El objetivo de este trabajo fue determinar la proporción de mujeres de 45 a 64 años afiliadas a un plan de medicina prepaga de Buenos Aires, Argentina, que realizaron al menos una densitometría ósea de cadera durante 2011 y no cumplían criterios para el rastreo. Se realizó un estudio observacional de corte transversal. Se identificaron 4.310 mujeres de este rango etario que se realizaron una densitometría ósea, entre las que se seleccionó una muestra aleatorizada de 401 mujeres y se obtuvieron datos completos para 178 mujeres. Para determinar si el rastreo era apropiado se utilizaron dos criterios: 1) tener un riesgo de fractura a 10 años mayor que una mujer de 65 años (regla FRAX®); 2) presentar al menos un factor de riesgo de fractura. Un 86,5% de las densitometrías óseas fueron realizadas en mujeres cuyo riesgo estimado por FRAX® no superaba el umbral mínimo recomendado, constatándose osteoporosis en el 5,8% y osteopenia en el 61,0%. En relación con el segundo criterio, el 49,4% no presentaba siquiera un factor de riesgo, documentándose osteoporosis en el 3,4%, y osteopenia en el 62,5%. Los resultados muestran que al menos la mitad de las mujeres no cumplía con los criterios de rastreo