Cochrane Sustainable Healthcare: evidence for action on too much medicine

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Medical excess threatens the health of individuals and the sustainability of health systems. Unnecessary tests, treatments, and diagnoses bring direct harm to people through adverse effects of interventions, psychosocial impacts of labelling, and overwhelming burden of treatment. Overuse and overdiagnosis also consumes scarce resources, leading to underuse and underdiagnosis in other areas, which indirectly harms patients. As healthcare spending grows all over the world, with poor correlation between increased costs and improved health in high‐income countries, there is growing recognition that much of that spending is unnecessary. Increased costs of healthcare also draws resources from other societal sectors capable of improving health and wellbeing for the population. By tackling the crisis of medical excess, we can reduce harm and prevent waste, making our health systems more sustainable and more beneficial for patients and societies.

Much work is already underway to identify medical excess and mitigate its harmful consequences. This includes: efforts to improve the trustworthiness of the evidence base through transparency and independence from commercial influence; explicit considerations of benefits, harms, costs, and burdens when making clinical guideline recommendations; campaigns to de‐implement or de‐intensify low‐value care; initiatives to tackle the problem of inappropriately expanding disease definitions; and participatory approaches to the development of care plans that are evidence‐informed, responsive to problematic situations of patients, and minimally disruptive. Generally, such efforts focus narrowly on particular manifestations of the problem rather than on broader considerations of the cultural, political, social, professional, scientific, and financial processes that encourage us to do something rather than nothing, even when it may do more harm than good.

The best available evidence demonstrates that reducing medical excess is very challenging and that there is a pressing need for more and broader work on how to move forward. Currently, neither primary research nor evidence synthesis adequately or routinely consider the harms of medical interventions or diagnoses. Although health guidelines are increasingly considering resource use, clinical policy statements typically remain agnostic about resource consideration, undermining rational prioritization of financial and human resources within our societies. Involvement of patients and the public in policymaking, research, clinical decision making, and implementation remains patchy and with limited impact, resulting in poor appreciation of what gives meaning to patients. To decide what constitutes ‘low value care’ is a challenge in itself, but even for interventions for which there is strong evidence that they bring limited value to patients, de‐implementation is extraordinarily difficult to carry through.

We need an evidence base better suited to support sustainable decisions about healthcare. To do this, an increased sensitivity to and focus on tackling medical excess is needed at all points in the evidence chain, including primary research, evidence synthesis, guideline development, policy making, communication with the public, and clinical care for patients.

Cochrane Sustainable Healthcare is a new Cochrane group focused on addressing medical excess. In essence, we aim to develop a global network for collaboration to more closely integrate processes that are often independent from each other. These include, but are not limited to, evidence production, evidence synthesis, prioritization of research questions, policymaking, guideline development and implementation, professional education, quality improvement and measurement, and clinical decision making. Our primary goals are to enhance the relevance of primary research and evidence synthesis to tackle medical excess, and to increase the use of that evidence to enable more sustainable healthcare for individual patients and societies.

We need novel approaches and methods to build on the existing work of many people and organizations around the world. Our aim is to collaborate with partners within and beyond Cochrane on activities ranging from short‐term research projects to longer‐term reform initiatives. Key priorities in the work of Cochrane Sustainable Healthcare will include, but are not limited to, the following areas:

• To develop fundamental reforms to evidence production and synthesis methods, so that research on medical diagnoses and interventions addresses potential harms as well as benefits.

• To push for a broad consideration of resource use at all steps in the evidence chain in order to promote a more sensible prioritization of financial and human resources for societies and to take the treatment burden for individual patients adequately into account.

• To contribute to research on when and how de‐implementation and de‐intensification of medical interventions and diagnoses is best done, without causing harm to patients, de‐professionalizing clinicians, or counteracting shared decision‐making processes.

• To elaborate, assess, and promote innovative methods for communication with patients and the general public about the benefits and harms of medical interventions and diagnoses, as well as the uncertainty of such estimates.

Crucial in this work is a high dose of humility. As for all medical research, it is of great importance not to spin results or overstate the evidence base about overuse and overdiagnosis. Decisions about de‐implementation and de‐intensification of medical interventions need to build on strong evidence, with a fundamental respect for the autonomy, context and preferences of the individual patient. An increased understanding of the different perspectives and challenges for each of the stakeholders in the chain between evidence and practice is essential.

Our vision is to support and augment the important work already performed in this area and to facilitate synergistic effects. We want to do this by creating a broad international collaboration and by partnering with primary researchers, funders of research, organizations working with evidence synthesis, guideline developers, policy makers, health systems organizations, professional medical associations, citizen and patient organizations, and the general public. We welcome anyone who is interested in this initiative to contact us via sustainablehealthcare.cochrane.org.

In conclusion, medical excess threatens the health of individuals and poses challenges for health system sustainability. The situation is urgent, and the need for novel approaches to tackle these issues is increasingly recognized. An intensified focus on projects and initiatives that cross the traditional boundaries between the different stakeholders in the evidence chain is required. The reasons for these challenges are diverse and complex, and so are the solutions – a strong collaboration integrating differing and sometimes contradictory perspectives is indicated. This will undoubtedly be challenging, but a more sustainable healthcare will benefit individual patients, as well as our communities.

Acknowledgements

RM initiated the idea and MJ wrote the first draft of the manuscript. All authors contributed to the development of the paper, through their ideas and their work, and all were engaged in drafting the manuscript. MJ is the guarantor. All authors write as individuals, rather than representatives of the organizations in which they are employed.

Feedback on this editorial and proposals for future editorials are welcome.

End Notes

Declarations of interest

The authors have completed the ICMJE form for disclosure of potential conflicts of interest. MJ is the Director of Cochrane Sustainable Healthcare and will seek grants to support the group. MJ is also employed part‐time by Cochrane Sweden. LB reports payment from Cochrane to the University of Sydney for LB's time as Senior Editor of the Cochrane Public Health and Health Systems Network. SW is co‐author of the book Overdiagnosed (but all book payments have been donated to charity). SW also served as an expert witness in testosterone litigation for plaintiffs. SW also cofounded Informulary, a company that provided transparent information about the benefits, harms and uncertainties of prescription drugs (the company has been inactive since 2016). RM reports payment from Cochrane Australia for hosting a podcast, unrelated to this Editorial.

Provenance and peer review

This editorial was commissioned based on a proposal by Cochrane Sustainable Healthcare and it was not peer reviewed.