With huge advances made in technology, a fee-for-service approach and a zero-risk philosophy, medical care is becoming more expensive. Procedures may not be necessary, but they always come at a high cost. Following Switzerland’s shift towards Smarter Medicine, the entire healthcare business is becoming choosier about the care it provides.
The leaps forward in medicine made as technology develops are the main advantage. But the side effect is the uncontrolled rise in the number of medical services, sometimes adding little value but often coming with a high cost and potentially high risk. Americans were the first to stay stop. The Choosing Wisely campaign launched in 2011 seriously re-examined the choices made in healthcare, and the movement is spreading throughout the globe.
The Swiss transposed it in 2014 under the name “Smarter Medicine”. The concept is simple: to encourage as many medical professions as possible to list the top five unnecessary treatments in their field. “The first list published in Switzerland was general internal medicine provided as outpatient care,” says Jean-Michel Gaspoz, Chairman of the national Smarter Medicine organisation and expert in general internal medicine and cardiology at the Clinique des Grangettes in Chêne-Bougeries. The five internal medicine procedures whose risk is believed to potentially outweigh their effectiveness include X-rays for patients with non-specific lower back pain lasting less than six weeks, antibiotic prescribing for non-severe upper respiratory tract infections, and pre-operative chest X-rays when no thoracic disease is suspected.
Since then, eight medical speciality societies have published their top five unnecessary medical acts, and seven others are preparing their list. “We’re far from the 80 partner societies in the United States, but Swiss healthcare professionals are becoming increasingly aware of the need to stop wasteful healthcare,” Dr Gaspoz says. However, the Chairman of Smarter Medicine points out that the organisation is not anti-technology. “On the contrary, the money saved can go into costly but highly advanced procedures that truly help the patient.” The campaign focuses on the patient rather than “reducing healthcare costs,” the doctor adds. The organisation’s next objective is to better integrate patients into the process. “In October we launched a campaign to encourage patients to talk to their doctor and not hesitate to ask questions about planned tests and treatments.”
“The top five is great, but what are individuals supposed to do with these lists?” asks Joy Demeulemeester, from the Swiss Patients Federation. She believes that the best weapon against unnecessary medical acts is information. “To have any control over the decisions made about their health and to make sure they are in line with their wishes, patients have to act like consumers: get information about available treatments from reliable sources, ask for a second opinion, compare, assess the relevance and disadvantages of treatment options and, in some cases, even consider the value for money.”
Patients in French-speaking Switzerland can get reliable information online, on the websites of Planète Santé, Revue Médicale Suisse or the various university hospitals.
“They should not hesitate to ask their doctor where they can get additional information. Online medical prescriptions are a good source!”
Joy Demeulemeester also advises patients to “carefully prepare their doctor’s appointment”, with a list of questions they want to ask. They should also take notes during the visit, as studies have shown that patients forget up to 80% of what was said after the consultation. And what they remember is not always accurate.”
Three years ago, the French-speaking Swiss Consumer Federation launched a pilot project called “Tous Consom’Acteurs de la Santé” (all healthcare consum’actors), to get citizens more involved in healthcare. The purpose was to train volunteers to engage with healthcare providers and act as an interface with patients, medical research and public authorities.
Smarter Medicine had barely made a name for itself in the world of Swiss healthcare – a Smarter Medicine survey showed that six out of ten doctors in French-speaking Switzerland have heard of the campaign – when another movement, Smarter Hospital, got off the ground. The programme brings together partner medical institutions that are actively initiating projects to support reasonable medical care. Geneva University Hospitals (HUG), which have joined the Smarter Hospital programme, “have already developed 47 projects across different units,” Dr Gaspoz says. An intensive campaign against unnecessary benzodiazepine prescribing was introduced at the Ticino-based hospital Ente Ospedaliero Cantonale (EOC). Meanwhile, the management at Triemlispital in Zurich is preparing to launch “several concrete projects within the next few months”. The Chairman of the Smarter Medicine organisation says that the fact that “hospitals, and not only medical associations, are also are taking responsibility in the fight against unnecessary treatments and wasteful care is an important sign.”
Lausanne University Hospital (CHUV) is also playing its part. Its 2019-2023 strategic plan covers a “programme to apply Smarter Medicine recommendations that are relevant to hospitals”. These actions include limiting blood transfusions and the use of benzodiazepines and sedative hypnotic drugs; avoiding unnecessary diagnostic exams and urinary catheters; and it also means getting patients to walk again as soon as they can.
Early patient mobility is CHUV’s main Smarter Medicine objective for 2019, says Jean-Blaise Wasserfallen, the hospital’s Associate Medical Director. This project was initiated by Guillaume Roulet, chief of the physiotherapy service, and is precisely one of the top five recommendations in hospital general internal medicine. “Two-thirds of geriatric patients leave the hospital with a new functional dependence,” he notes. Why? “Because we move much less at the hospital than at home because we don’t have to get up to make tea, answer the door or go to the toilet.” Mobility experts were appointed to help with this project.
“Our mobility experts are in charge of teaching healthcare staff, patients and those close to them about the importance of mobility, to develop a culture of letting the patient handle things rather than doing it for them,” Mr Roulet says.
“For example, we’ve reversed the protocol of medical visits. Now all patients have to be in a sitting position for their exams, which forces them to move.” Initially designed for the internal medicine department, the early patient mobility programme is expected to be rolled out gradually throughout the hospital.
CHUV’s other short-term objectives under the Smarter Medicine programme include scaling back the top five unnecessary treatments. “That will require a lot of education and communication, because it’s a real change in culture,” Mr Wasserfallen says. Another significant challenge facing supporters of Smarter Medicine is coming up with indicators to measure how well the new culture is working. “We’re mainly focusing on establishing structured protocols,” says Professor Gérard Waeber, who heads the Department of Medicine at CHUV. “These protocols will help us provide more consistent care, and the performance indicators can be compared with other university hospitals in Switzerland.” Isabelle Lehn, CHUV Healthcare Director, notes with “great interest” this shift towards care focused on the patient’s (real) needs. “We are finally emerging from the period of excessive safety and, at the same time, learning to consider the patient a true partner.”
People over 65 take an average of 5.6 medications a day for those living at home, versus 9.3 for those in long-term care. A compilation of several Europe-wide studies published in 2008 by JAMA Internal Medicine stated that 21% of drugs prescribed in outpatient care, 35% of drugs prescribed in hospital and 60% of drugs prescribed in long-term care were potentially inappropriate.
Alarmed by these figures and more specifically by the amount of psychotropics taken by elderly patients, healthcare authorities in the Canton of Vaud provided funding (2 million Swiss francs per year in 2017) to standardise the use of quality circles at the canton’s long-term care facilities. That means optimising the choice and use of medications prescribed at the establishment. Each circle includes the pharmacist, the facility’s head physician and head nurse. “They meet several times a year to establish a consensus about the choice and use of drugs, which is then applied to all residents,” says Olivier Bugnon, head pharmacist at the Policlinic Medical University (PMU) in Lausanne and director of a study on deprescribing opportunities at long-term care facilities, supported by the Smarter Health Care research programme of the Swiss National Science Foundation (SNSF).
If deprescribing – or, reducing the dose or discontinuing the use of some drugs – is a key focus of the quality circles, the expert warns that “under-medicalisation is almost as much of a problem as over-medicalisation in long-term care. So we need to start over from scratch, prescribing neither too much nor too little, and make medicalisation an individual concern.” Mr Bugnon points to the example of a patient with seven different illnesses. “There’s no miracle solution. We have to carefully analyse the individual’s needs, priorities, the interaction between different drugs, etc. Only then can we choose which ones to deprescribe and which to add.”
Starting over from scratch is relatively easy at a hospital or healthcare facility, where all healthcare staff have access to the patient’s records, but it is more complicated for patients who live at home. “It is not rare for the general practitioner to prescribe certain drugs and a specialist to prescribe others, while on top of that the patient is taking medication prescribed during a hospital stay. Not to mention those who self-medicate,” says Margarita Cambra, director of development of professional practices of Avasad (Vaud association for assistance and home care). Admittedly, “our nurses can help sort through that, but only if they have access to all the information.” Margarita Cambra is hopeful that the future electronic health record – the Swiss Federal law of 5 June 2018 launched its implementation – will “finally give all healthcare providers involved an overview of a patient’s treatments”. Olivier Bugnon shares this optimism, “as long as everyone plays their part and includes information in the record”.
The Smarter Medicine organisation is unambiguously clear that its main goal is not to reduce healthcare costs. But in many cases, a decrease in costs is a positive side effect of enhancing the quality of care. “What is really interesting with Smarter Medicine is that it goes against the idea that ‘quality does not come cheap’,” says Brigitte Rorive, head of finance at HUG. “The opposite is true. Quality is what ends up bringing costs down. Being wasteful, however, is costly: duplicate testing, unnecessary procedures, etc.”
Ms Rorive believes that current financing systems go against the Smarter Medicine philosophy as they are based “either per medical service or on fixed amounts per hospital admission, which are themselves based on a fee for service principle”. Healthcare providers are therefore encouraged to increase the number of services they provide to be paid more. “The first way to improve the system would be to reward quality over quantity.” That would mean “selecting five or six key indicators such as mortality, readmission, complications and repeat operations.” Service providers that do not meet targets would be penalised, as “their services would not be reimbursed as much”.
This approach could even go further. “Action should be taken at a much earlier stage, by focusing healthcare policy on prevention. Hospitalisation – which accounts for 35% of healthcare costs in Switzerland, compared with 2.4% for prevention – should be considered a last resort.” Ms Rorive points to the example of Denmark, where an ambitious “superhospital” project is being developed. “Eventually, anything that can be handled as outpatient care would be, and the country with a population of 6 million would only have about 20 hospitals. As a comparison, Switzerland has about 200.” Another solution inspired by other countries? The bundled payment model developed under the Obama administration bases pricing on episodes of care covering different links in the chain (hospital, home care, etc.). “A standard pathway is set, which encourages each service provider to come in at the right time with the right service in the right amount. But this model only works for procedures that can be standardised,” the expert admits.
Based on the Choosing Wisely campaign in North America, the Swiss organisation Smarter Medicine, created in 2017, publishes lists of five unnecessary medical services in each field of expertise. These lists of recommendations are drawn up by speciality societies and are designed for specialists in that area. Below are a few excerpts from these recommendations. The full version is available on the Smarter Medicine website.
Do not prescribe benzodiazepines or other sedative hypnotics for elderly patients if the primary intention is to treat insomnia, restlessness or delusions.
Do not prescribe antibiotics for non-severe upper respiratory tract infections.
Do not insert a urinary catheter or leave one in place only for practical reasons (urinary incontinence, monitoring urine output) with patients outside of intensive care.
Limit deep sedation for patients on mechanical ventilation for at least partial daily awakening.
Do not begin care for low-risk prostate cancer without looking into the possibility of active surveillance.
Do not begin chronic dialysis without guaranteeing a shared decision-making process with the patient and their family.
As evidence of the awareness to issues raised by Smarter Medicine, the new Swiss Oath, a modern version of the Hippocratic Oath, emphasises expressing oneself “understandably” to the patient about “judicious” measures and refusing “financial advantages or services”.
The profession did not wait for the Smarter Medicine programme to set best practices. The campaign follows on from other initiatives, such as Evidence-Based Medicine (EBM), which is defined as the “conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients” by David Sackett, a Canadian doctor and founder of the Oxford Centre for Evidence-Based Medicine. The medical profession is becoming aware of its inherent waste and is pursuing its rationalisation efforts.
Taking a more philosophical viewpoint, physician and theologian Bertrand Kiefer wrote in the journal Revue Médicale Suisse in 2016 that excessive medical care often acts as a cover to hide our fear of death. “Medicine plays the role of symbolic compensation,” the theologian says, “which used to be played by rites, religions and myths.”
To help patients make fully informed decisions about the treatments suggested to them, Smarter Medicine has prepared a list of five questions that it recommends asking during doctor appointments.
Overdiagnosis refers to the revelation of an actual disease that would never have caused symptoms during a patient’s lifetime. Overdiagnosis can lead to intensive treatments and cause considerable unnecessary psychological distress to patients. One of the frequently cited examples is slow-growing prostate cancer that would not have threatened the patient’s health.
An after-effect of overdiagnosis, overtreatment is the tendency to treat a disease and give the illusion of recovery, even though the patient would not have experienced any harmful effects on their health without the treatment.
Percentage of healthcare spending for non-medically indicated treatments.
Percentage of patients who say that they themselves or someone they know felt they had an unnecessary medical service.
Percentage of people who stated that they have felt that they did not understand everything during a medical consultation.
of medication prescribed in hospital is potentially inappropriate.
of medication prescribed in long-term care facilities is potentially inappropriate.
is the average number of drugs taken a day by elderly patients living at home. The term polypharmacy is used when a patient takes more than five medications a day.