Managing de-implementation in general practice

Medical research never stays still, generating new information and techniques every year, month and day. This process constantly feeds into the creation and updating of treatment guidelines and recommendations, which are often then launched with great fanfare and publicity.
 
But there is a flipside; this leaves behind older recommendations that have been shown to be not so effective after all – or perhaps even harmful.
 
The process of ceasing to use these recommendations is known as de-implementation.

Dr Justin Coleman, a GP and medical writer, has a special interest in this process, but he understands that keeping up with current evidence can be difficult.
 
‘I think GPs are generally quite good at it, because it really is part of the role,’ he told newsGP. ‘It is very difficult as a GP, though, to be the first to hear about a change of practise.

‘A specialist keeping up-to-date in their own field is far easier than a GP keeping up-to-date in general practice, because the variety of medical conditions is 10 or 20 times higher than for some of the specialties.’
 
Another thing that contributes to this difficulty is the fact there is often far less impetus to spread information about obsolete recommendations than there is for launching a new guideline.
 
‘There’s almost always no corporate body that benefits from that [de-implementation] information being disseminated, and therefore it tends to sit in academic journals and wait until someone comes along and does the next guideline and reports on it,’ Dr Coleman explained.

‘So there’s a significant lag time, often years between the evidence coming out and that old practice being ceased.’
 
Simple human nature can also be a barrier to letting go of older recommendations, although it can be hard to judge the overall efficacy of a treatment as a single practitioner.
 
‘We get used to doing things a certain way, referring for certain types of surgery or using certain treatment,’ Dr Coleman said. ‘And a proportion of the people we send off with these things seem to do well.
 
‘But it’s very hard as an individual to really weigh that up against how the same person would have done if we hadn’t sent them off for treatment. That’s why I think we do need these large studies, because it takes a fair bit of impetus for doctors to change what they’ve always done.’
 
While the occasional intervention may turn out to be potentially harmful, for the most part treatments are de-implemented because it is found they are actually not of much use to most people.
 
‘When [a new treatment] comes out and everyone starts using it, it comes with very high expectations that tend to reduce over the years,’ Dr Coleman said.
 
‘Eventually someone, usually at a university or an individual who’s not financially involved, suspects it doesn’t work much at all and conducts a high-quality study. It then might turn out that the treatment is neutral, as in it doesn’t do much good and doesn’t do much harm – just financial harm.
 
‘Of course there are exceptions; some things are shown to have been harmful all along. But the majority often turn out to be not worth doing because they don’t work very well.’
 
Sometimes treatments are effective within a certain limited population, but have become more widely used as a result of ‘treatment creep’. A good example of this is testosterone treatment.
 
‘The pushback comes when the medical community has stretched the boundaries [of usage] from people in whom the treatment is very helpful into the broader population, usually a far larger population,’ Dr Coleman said.
 
‘Then the new evidence comes out that in that larger population, the treatment doesn’t do much good at all. But people who have used it at the thin end of the wedge, so men with significant testosterone deficiency, are so convinced by its worth they are reluctant to accept it doesn’t do good for other groups.
 
‘In a lot of these cases, the new guidelines are really drawing the treatment back to the small numbers of extreme cases where it was used in the first place, and pulling back that drift.’
 
One way that GPs can keep up-to-date with the most recent evidence is by keeping an eye on updates to existing guidelines, such as the recently released third edition of the RACGP’s Guidelines for the implementation of prevention in the general practice setting (Green Book). Modern communication technology also offers a variety of avenues for keeping up with the changes.
 
‘There are forums, particularly in social media, where there are discussions of something a GP has always done one way, and someone points out there’s now evidence that it doesn’t work,’ Dr Coleman said.
 
Dr Coleman believes it can also pay to keep an eye on more traditional sources.
 
‘For example, there are Cochrane reviews or meta-analyses that demonstrate what we thought we knew was right is no longer right,’ he said.
 
‘Classics in the last year or so have involved a sham surgery trial that showed, in general, arthroscopic repairs of shoulders or rotator cuffs didn’t work, and similar for stents for coronary artery disease in many circumstances, and knee arthroscopies in older people with osteoarthritis.

‘It’s not as if these things never work, but they don’t work in common circumstances.
 
‘So there are examples of good trials that are done which really do tip decades of practise on its head.’
 
RACGP members will also be able to access further help in the future, as the college is in the process of setting up a working group under the RACGP Expert Committee – Quality Care, which will be chaired by Dr Coleman.
 
‘The new working group will be focused on trying to help out with this stuff and let GPs know when the evidence no longer supports old treatment,’ Dr Coleman said.

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