Tiago Villanueva: Quaternary prevention

Tiago_Villanueva The primary care innovation seminars group, a primary healthcare think tank that was created in Spain in 2005, convened this weekend in Barcelona. The group used to meet several times a year in Madrid. This year, group members gathered for the first time outside the Spanish capital, with the added bonus of the presence of many leading GPs from around the world, who were in Barcelona for the annual meeting of the World Organization of Family Doctors International Classification Committee (WICC). Many of the WICC members were speakers at the seminar, including Juan Gérvas, a Spanish GP and leader of the primary care innovation seminars group.

Domhnall Macauley and I have previously mentioned the concept of quaternary prevention, but few can describe it like Marc Jamoulle, a Belgian GP and one of the world’s leading experts in quaternary prevention, who says it is all about “the action taken to identify the patient at risk of overmedicalisation, to protect him from new medical interventions, and to suggest other interventions to him, which are ethically acceptable.”

The concept of quaternary prevention has been gaining momentum among the primary health care academic community over the last few years, but it has been known for decades. Sometimes, the best approach to a health problem is acknowledging when to avoid providing unnecessary healthcare. For example, one participant in the seminar said that for the last 30 years a military hospital in the United States has considered it acceptable not to treat burns patients with burns in over 95% of their body surface due to the poor prognosis of such patients.

Gustavo Gusso, president of the Brazilian Society of Family Medicine, said that in order to successfully teach quaternary prevention, we need to produce relevant scientific information, including protocols that start with the symptom rather than with the disease. He pointed out that even though diagnosis and disease centered protocols have many limitations, we were failing to do better.

Juan Gérvas added that, even though many patients these days have multiple health problems, conferences about single health problems and diseases remain the norm (for example, diabetes), while conferences about multimorbidity remain rare. So he called for participation in a meeting in 2012 organised by the Spanish Primary Care Network about schizophrenic diabetic patients, and wondered if anyone was aware of guidelines for diabetic patients with schizophrenia. No one responded.

One of the key ideas Gérvas conveyed was that it is pivotal to keep patients away from the health system when they don’t need healthcare at all, as well as being extremely cautious about the dangers of expanding access to health services. For example, introducing radiology services in primary health care may cause unnecessary harm if used excessively.

He also mentioned the example of the King of Spain, Don Juan Carlos, who goes to Barcelona every year to have a “check-up,” encouraging many Spanish people to do the same and therefore to potentially damage their health. In the case of the King, he said that a pulmonary nodule was found last year that was most likely benign, but which still triggered potentially avoidable surgery that subsequentely prevented the King from attending the football World Cup in South Africa. Vicente Ortún, dean of the Faculty of Economics of the Pompeu Fabra University, in Barcelona, emphasised that quaternary prevention increases both effectiveness and equity.

Leading Spanish health economist Beatriz López-Valcarcel, from the University of Las Palmas, in the Canary Islands, explained that even though assisted reproduction was successful only in about 7% of Australian women aged between 40 and 44 years, the Australian Government still decided to keep funding it. It may not make sense to clinicians to fund potentially useless medical interventions, but she stressed the idea that the goal of the health system was not to save, but rather to attain a balance between health benefits and risks, and between effectiveness and costs. So keep this in mind the next time you hear about politicians making decisions about the health system that don’t seem to make any sense.

Tiago Villanueva is a GP based in Portugal and a former BMJ clegg scholar and editor, Student BMJ. He personally paid for all the travel expenses to attend the seminar in Barcelona.

  • Rajeev Gupta

    Overmedication is rampant in countries such as India. While there are millions who do not have acces to healthcare and approproate treatment there are millions who bear the brunt of undue and harmful investigations and overuse of drugs.
    Some recent examples
    (i) it is common to observe use of CT scans to sequentialy diagnose and assess response to therapies to pneumonias in many tertiary (sic!) hospitals.
    (ii) overprescription and cavalier attitude in treatment of infections have led to widespread NDM-1 gram negative bacteria. Almost all intensive care units are grappling with cases of multi-drug resistant E coli, Klebsiella and Acinetobacter infections.
    (ii) it is also common for patients with established coronary heart disease to have over prescription of vitamins which sometime replace statins. Undue use of stents and CABG is another story.
    It is imperative that the concept of quarternary prevention spreads in all parts of the world.
    Rajeev Gupta