What do we know?

Excessive use of overdiagnosis and overtreatment is one of the cuases of tje lack of quality care on the side of health systems and in all countries. [1] Refers to the provisiono of helath services in circumstances in which the potential to harm the patient excedes the potencial benefits. [2]  It represents a risk to the safety [3] and the sustainability  of helath systems. [4-5] Excessive use occurs when the tests and treatments used are benefical for the appropriate patient, but useless for the patient who does not need them. It also happens when ineffective or even harmful interventions are applied to patients.

Although, conceptually there is no doubt about what excessive use is, these low-value practises can´t alway be easily identified.

In Spain, in april 2013, the Mnistry of Health approved, at the proposal of the Spanish Society of Medicine Internal (SEMI), the so-called “Commitment of Quality of Scientific Societies of Spain” to reduce overuse. The General Subbdirectorate of Quiality an Cohesion of the Ministry, the Aragonese Institute of Health Science (with the participation of the GuiaSalud team), and the SEMI are responsible for coordinating this initiative, which is part of the activities of the Spanish Network of Evaluation of Technologies and Services Organitations of the National Health System. [10] The repository of these “Don´t Do” recommendations is hoste don the website of the Ministry of Health (https://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/cal_sscc.htm). It currently has 190 recommendations at professionals, patients, institutions and health authorities. In addition to this initiative, some autonomous communities have also joined the initiative.

The volumen of patients undergoing low-value practises varies, depending on the type of practice and the country. Between 1 and 80%. [1] The use of potentially inappropriate drugs could reach up to 57.6%[11] in some studies. In Spain, the polypharmacy has gone from 2.5% (2005)to 8.9% (2015). In absolute terms, polymedication has increased more among women (from 2.7% to 9.5%) tan amog men (from 2.3% to 8.5%). [12]

In primary care in Spain, the SOBRINA study [13] has shown that between 2018 and 2019, 55.1% of patients received at least one indication classified as “Don´t do” with respect to benzodiazepines, NSAIDs, lipid-lowering agents, antibiotics, paracetamol , and ibuprofen. The percentage of clinical histories with more than one “Don´t do” was 18.5% in people over 29 years of age. Women received a greater number of prescriptions that ignored “Don’t Do” recommendations (frequency adjusted rate 49.4%) than men (frequency adjusted rate 41.8%) (p<0.0001).

In terms of costs, in the US, where 18% of gross domestic product is spent on healthcare, overuse represents an additional annual cost that, according to the most optimistic estimates[5], ranges from $75 .7 and $101.2 billion, while other studies place the figure at $158-226 billion.[14] In Spain, in primary care, we have calculated that the extra cost of ignoring the recommendations on the proper use of benzodiazepines, NSAIDs, lipid-lowering agents, paracetamol and ibuprofen, amounts to 290 million euros (2.8% of total pharmaceutical spending in 2018 considering only the cost of prescriptions issued).

Excessive use has been linked to security incidents. In the case of hospitals, between 0.2% and 15.0% of  hospitslised patients suffer adverse events due to a low-value practice [15] and, in primary care, in our SOBRINA study we found that when “Don´t do” recommendations are ignored, 5.1% of adult patients suffered adverse events.[16] Women suffered a greater number of adverse events than men when these “Don’t do” were ignored (frequency-adjusted rates 4.9% vs 4.0%, p=0.047). This subject has begun to be analyzed and our group is leading the first studies in primary care at an international level.

There is evidence showing that gender, as a social construct, has a substantial impact on health behaviors, access to and use of health systems, and health system responses.[20] Gender bias can be defined as a systematic error in the social construction of the history of the disease, its symptoms, which produces inequitable responses to health problems by health services, as well as discriminatory responses between men and women. women by professionals.[21] This bias can occur at any time in the care process, but there are hardly any interventions aimed at eliminating it.[22] The presence of gender inequalities in health care is associated with the belief that the risks between men and women are similar, when in fact they are not, which leads to women’s problems being left unaddressed. effective; and the assumption that there are differences in aspects in which they are the same and that what changes is the way in which health professionals deal with them. The result of these biases has been not to address differences in the experience of the disease, not to assume differences in the expression of symptoms according to gender, with many women diagnosed with non-specific symptoms and, finally, differences in the provision of health services. . For this reason, womens centered health care has been requested.[23-24]

The fact that some diseases are attributed more to men and others to women has generated a bias in the establishment of diagnostic criteria, in the access to complementary tests or treatments [16] that must be considered in the analysis of the causes of the overuse. Although there are several theoretical approaches to apply gender analysis to health, the most widely used are the Liverpool School of Tropical Medicine Model (2001) and the one proposed by the Women’s Knowledge Network and Gender Equity, in a report for the WHO  Social Affairs Commission . Health Determinants. The first establishes a set of questions to consider when analyzing the differences or similarities between women and men. The second helps to explain the role of gender as a determinant of health and helps to identify how gender biases are introduced into health systems. Professor Ruiz Cantero’s proposal to carry out epidemiological studies is another relevant source.[20] In Spain, the Red-Caps (Network of Women Health Professionals) promotes training, research and scientific dissemination activities with a gender perspective and is a benchmark in this type of approach

Results from comparisons of prescriptions ignoring “Don’t do” recommendations between women and men can be classified into one of three categories:

– Prescriptions ignoring similar “Don’t Do” recommendations among male and female patients (e.g., NSAID prescription in patients with high blood pressure, heart failure, chronic kidney disease, or cirrhosis of the liver. Mira et al, J Patient Safety. 2020 (in print).

– Prescriptions that ignore different “Don’t Do” recommendations between male and female patients due to gender-specific factors (e.g., drugs with different pharmacokinetic profiles between men and women).

– Prescriptions that ignore the “Don´t Do” recommendations that are different between male and female patients and that are attributable to gender factors (e.g., on the prescription of anxiolytics and hypnotics and analgesics – Martinez-Cengotitabengoa, et al. Rev Psiquiatr Salud Ment 2018; 11: 12-8; Chilet-Rosell et al. Gac Sanit 2013; 27: 135-42).

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