The first ophthalmic Choosing Wisely recommendations in Finland for glaucoma and wet age‐related macular degeneration
2019; Wiley; Volume: 97; Issue: 5 Linguagem: Inglês
10.1111/aos.14031
ISSN1755-3768
AutoresRaimo Tuuminen, Raija Sipilä, Jorma Komulainen, Ville Saarela, Kai Kaarniranta, Anja Tuulonen,
Tópico(s)Retinal and Optic Conditions
ResumoActa OphthalmologicaVolume 97, Issue 5 p. e808-e810 Letter to the EditorFree Access The first ophthalmic Choosing Wisely recommendations in Finland for glaucoma and wet age-related macular degeneration Raimo Tuuminen, Raimo Tuuminen orcid.org/0000-0003-1550-8125 Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland Unit of Ophthalmology, Kymenlaakso Central Hospital, Kotka, FinlandSearch for more papers by this authorRaija Sipilä, Raija Sipilä The Finnish Medical Society Duodecim, Helsinki, FinlandSearch for more papers by this authorJorma Komulainen, Jorma Komulainen The Finnish Medical Society Duodecim, Helsinki, FinlandSearch for more papers by this authorVille Saarela, Ville Saarela PEDEGO Research Unit and Medical Research Center, University of Oulu, Oulu, Finland Department of Ophthalmology, Oulu University Hospital, Oulu, FinlandSearch for more papers by this authorKai Kaarniranta, Kai Kaarniranta Department of Ophthalmology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland Department of Ophthalmology, Kuopio University Hospital, Kuopio, FinlandSearch for more papers by this authorAnja Tuulonen, Corresponding Author Anja Tuulonen anja.tuulonen@pshp.fi Tays Eye Centre, Tampere University Hospital, Tampere, Finland Correspondence: Anja Tuulonen, MD, PhD, FEBO Tays Eye Centre Tampere University Hospital PO BOX 2000 FIN-33521 Tampere Finland Tel: +358 40 779 6278 Fax: +358 3 311 64336 Email: anja.tuulonen@pshp.fiSearch for more papers by this author Raimo Tuuminen, Raimo Tuuminen orcid.org/0000-0003-1550-8125 Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland Unit of Ophthalmology, Kymenlaakso Central Hospital, Kotka, FinlandSearch for more papers by this authorRaija Sipilä, Raija Sipilä The Finnish Medical Society Duodecim, Helsinki, FinlandSearch for more papers by this authorJorma Komulainen, Jorma Komulainen The Finnish Medical Society Duodecim, Helsinki, FinlandSearch for more papers by this authorVille Saarela, Ville Saarela PEDEGO Research Unit and Medical Research Center, University of Oulu, Oulu, Finland Department of Ophthalmology, Oulu University Hospital, Oulu, FinlandSearch for more papers by this authorKai Kaarniranta, Kai Kaarniranta Department of Ophthalmology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland Department of Ophthalmology, Kuopio University Hospital, Kuopio, FinlandSearch for more papers by this authorAnja Tuulonen, Corresponding Author Anja Tuulonen anja.tuulonen@pshp.fi Tays Eye Centre, Tampere University Hospital, Tampere, Finland Correspondence: Anja Tuulonen, MD, PhD, FEBO Tays Eye Centre Tampere University Hospital PO BOX 2000 FIN-33521 Tampere Finland Tel: +358 40 779 6278 Fax: +358 3 311 64336 Email: anja.tuulonen@pshp.fiSearch for more papers by this author First published: 18 January 2019 https://doi.org/10.1111/aos.14031Citations: 8AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Editor, Growth in healthcare production and resources is assumed to lead to continuous improvement of well-being and health. However, already decades ago it was recognized that more health care may also incur counterintuitive effects (Fisher & Welch 1999, Table 1). Several medical speciality societies have initiated calling for physician leadership and responsibility to advocate cost-effective and just distribution of finite healthcare resources by advising clinicians what to do and what not to do, especially with missing or low-quality evidence (Parke et al. 2013). Table 1. Barriers for changing established practices and for changes in thinking models and beliefs in individual and system levels.a Current cultural and legal environments exert tremendous pressure to do more When we look for more to better, data that are inconsistent with our underlying beliefs are often either rejected or ignored Advanced, fast and seemingly easily interpretable diagnostic technologies as well as more frequent testing lead to more diagnoses Findings associated with ‘disease’ have become so subtle that even experts often disagree who has the diagnosis Delays in making diagnosis are strongly prioritized while harms of pseudodiseases are discounted or ignored Research efforts are missing a level of analysis, the system Although medicine in increasingly rooted in science, the practice of medicine is filled with uncertaintyb Market atmosphere a Fisher ES & Welch HG (1999): Avoiding the unintended consequences of growth in medical care. How might more be worse? JAMA 281: 446–453. b For example, in 2017 in Finland, the total number of anti-VEGF injections was 92000, including also other diagnosis than wAMD. When compared to 71000 wAMD in Sweden and considering the coverage of the registry, the number of wAMD injections was roughly about the same for 5.5 million Finns and for 10 million Swedes. Bevacizumab was injected in 79% cases in Finland compared to 24% in Sweden (http://rcsyd.se/makulareg/wp-content/uploads/sites/2/2018/11/%C3%85rsrapport-2017-Svenska-Makularegistret.pdf). In 2013, American Academy of Ophthalmology and American Association for Pediatric Ophthalmology and Strabismus released their top five lists for interventions which ophthalmologists and patients should question (Parke et al. 2013). By 2019, the Finnish Society Duodecim has published 92 Choosing Wisely recommendations for 55 medical entities with the first five for ophthalmology in 2018, based on Finnish national clinical practice guidelines for glaucoma and AMD (Tuulonen et al. 2014; Tuuminen et al. 2017) presented in English below. Avoid diagnosing glaucoma only on the basis of automated imaging instruments. Justifications: There is no consistent or generally approved definition of the diagnostic tests for glaucoma and their criteria in the scientific literature – nor is there evidence for either the most clinically effective or the most cost-effective tests and technologies to be used for the diagnosis and detection of progression to prevent glaucoma-induced visual disability (Tuulonen et al. 2014). The Cochrane review of 106 studies concluded that the accuracy of automated imaging tests for detecting manifest glaucoma was variable across studies and accuracy may have been overestimated due to the case–control design, which is a serious limitation of the current evidence base (Michelessi et al. 2015). In the Health Technology Assessment of imaging devices in community practice, the specificity for severe glaucoma of the best device was only 71% (Azuara-Blanco et al. 2016). Avoid nontargeted population screening for glaucoma because of lacking evidence that screening could prevent glaucoma-induced visual disability. Justifications: There is lack of high-quality studies indicating that any particular screening test or strategy policy reduces glaucoma-induced visual disability or is cost-effective. Avoid routine monitoring of diurnal intraocular pressure during follow-up of glaucoma. Justifications: The significance of measuring diurnal variation during follow-up in assessing the risk for progression of glaucoma is unclear. The number of studies is limited with nonoptimal quality. Avoid using ranibizumab and aflibercept as first-line therapy for wet AMD due to high costs. Justifications: Studies on the treatment of wet AMD with VEGF inhibitors (bevacizumab, ranibizumab, aflibercept) have failed to demonstrate clinically significant differences in the efficacy (anatomical and functional response) or safety of different treatment regimens over a follow-up period of a few years. The Council for Choices in Health Care within Ministry of Social Affairs and Health in Finland have stated that treatment of wet AMD with intravitreal bevacizumab is included in the publicly funded health service range of Finland (https://palveluvalikoima.fi/en/recommendations). The cost of bevacizumab in Finland is about 30–35 € compared to 700 € for ranibizumab and aflibercept. The cost of aflibercept can be substantially reduced by dividing the drug into three syringes. If the response of first-line drug is considered insufficient, treatment with another anti-VEGF drug may be warranted. Avoid initiating anti-VEGF therapy unless i) improvement of visual acuity or well-being can be expected; and ii) the harms or risks of treatment are expected to outweigh expected benefits. Justifications: In patients with a best spectacle-corrected visual acuity in the treated eye of less than 0.0625 decimals (ETDRS <20), there is little evidence of the anticipated benefits of treatment for the patient's functional capacity and quality of life. It is crucial to constantly and consciously consider sufficiency of care: both undertesting, undersdiagnosing and undertreatment – similar to overtesting, overdiagnosing and overtreatment. The latter increase the number of false positives, decrease quality of life and make it more difficult for severe cases to get appropriate care. References Azuara-Blanco A, Banister K, Boachie C et al. (2016): Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study). Health Technol Assess 20: 1– 168. Fisher ES & Welch HG (1999): Avoiding the unintended consequences of growth in medical care. How might more be worse? JAMA 281: 446– 453. Michelessi M, Lucenteforte E, Oddone F et al. (2015): Optic nerve head and fibre layer imaging for diagnosing glaucoma. Cochrane Database Syst Rev (11): CD008803. Parke DW 2nd, Coleman AL, Rich WL 3rd et al. (2013): Choosing Wisely: five ideas that physicians and patients can discuss. Ophthalmology 120: 443– 444. American Academy of Ophthalmology http://www.choosingwisely.org/societies/american-academy-of-ophthalmology/ and American Association for Pediatric Ophthalmology and Strabismus http://www.choosingwisely.org/societies/american-association-for-pediatric-ophthalmology-and-strabismus/) Tuulonen A, Luodonpää M, Määttä M et al. (2014): How to interpret evidence in everyday practice: The Finnish Current Care Guideline for open-angle glaucoma. English translation of the Finnish Current Care Guideline for Glaucoma. Available at: http://www.kaypahoito.fi/documents/25721/0/Glaucoma+Current+Care+Guideline+2014.pdf/ca4ca043-92fe-433c-91f2-ef9e31b2d2aa. Tuuminen R, Uusitalo-Järvinen H, Aaltonen V et al. (2017): The Finnish national guideline for diagnosis, treatment and follow-up of patients with wet age-related macular degeneration. Acta Ophthalmol 95: 1– 9. Citing Literature Volume97, Issue5August 2019Pages e808-e810 ReferencesRelatedInformation
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