Backing off

I know we’ve been away for a bit, and there are loads of good reasons (life, and that sort of stuff) but we are all sneakily hoping you are all still interested about how to put clinical evidence into clinical practice.

In The Gap there has been much written and spoken about the problems of overdiagnosis (coming up with a condition that doesn’t need treatment, or is so mild that treatment is actively harmful). The use of excessive oxygen saturation monitoring is one we should all be aware of in paediatrics, especially that branch that deals with wheezy snot balls. (Argh! Bronchiolitis. That’s what you’re meant to say, isn’t it?)

The fundamental problem with overdiagnosis and the consequent overtreatment seems to be “How do we know what will happen if we DON’T do something?” This fear of the possible consequence, the outcome of the counterfactual, is real and concerning. This might be letting children who are immunocompromised eat normal food [1], or not undertaking follow-up chest radiographs in kids with ’round’ pneumonia. [2]

The best ways to appraise the evidence for not doing would be the same as the evidence for doing; that is, the results of randomised controlled trials of the decreased intervention. In some areas (like the flashy but unhelpful video-assisted-intubation devices used in kids [3]) such trials exist. In other areas, we have non-randomised comparative data, and in others we may have single-arm studies showing that the ‘reduced’ approach leads to acceptably small levels of problems (for example, in low-intensity treatment of febrile neutropenia [4]). As with other interventional evidence, we need to weigh the possible biases and errors against the advantages and disadvantages of the management undertaken, and remember that side effects can be just as dangerous as disease effects. [5]

Being clear about why we are doing, or not-doing, is important. We should never do something ‘just in case’ or ‘just because we can’.

  • Archi

[1] http://dx.doi.org/10.1136/archdischild-2016-312125

[2] http://dx.doi.org/10.1136/archdischild-2017-313980

[3] Abdelgadir ISPhillips RSSingh DMoncreiff MPLumsden JLVideolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates)Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD011413. DOI: 10.1002/14651858.CD011413.pub2.

[4] Morgan, J.E., Cleminson, J., Atkin, K. et al. Support Care Cancer (2016) 24: 2651. https://doi.org/10.1007/s00520-016-3074-9

[5] Classification of treatment-related mortality in children with cancer: a systematic assessment Alexander, Sarah et al. The Lancet Oncology , Volume 16 , Issue 16 , e604 – e610

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