Less Is More

“Perfection is achieved,

not when there is nothing more to add,

but when there is nothing left to take away.”

‘Terre des hommes’ (1939)

Antoine de Saint-Exupéry (1900-1944)

For the title and epigraph of this editorial, I have chosen two phrases from authors that have nothing to do with medicine, but whose quotes masterfully summarize the topic at hand.

There is little doubt that medicine in general and surgery in particular have played decisive roles in securing our society's current levels of health, but we are equally sure that some of our actions have been of very limited use and may even have been harmful. In recent years, the term “low-value interventions” has been used to define diagnostic or therapeutic procedures whose efficacy has not been supported by scientific studies, with uncertain effectiveness, or those which may cause adverse effects in patients. In other words, these procedures are not cost-effective. It is estimated that, in certain ailments, the same health benefits could have been obtained with a cost reduction of between 16 and 99% and that, overall, efficiency could be increased by 20% if priority is given to the most cost-effective interventions.¹ There is an enormous potential to improve healthcare if these resources could be reinvested in other more appropriate areas with proven benefits.

In this context, several initiatives have arisen from different agencies, with the aim to limit these unnecessary interventions as much as possible. It is true, however, that the approaches and results vary. The pioneer in this frontier was the National Institute for Health and Care Excellence, an organism associated with the National Health Service of the United Kingdom. After the analysis performed by their own experts on the clinical guidelines they published, in 2007 the Institute created a list of common daily practices of healthcare services that do not have sufficient scientific support, which they recommended discontinuing. These are not specific prohibitions per se, but the prestige of the institution and its area of influence are used to make a clear message: “Do not do”.²

Afterwards, the “Choosing wisely” campaign was initiated and promoted by the American Board of Internal Medicine.³ In this case, the approach, as usually occurs in the American setting, was to transform a negative (“Do not do”) into a positive (“Choosing wisely”). Furthermore, scientific societies became involved in this campaign. Thus, in addition to the strong evidence procured by an independent entity, the recommendations were supported by professional associations.

In my opinion, the final products are somewhat irregular. On the one hand, the number of recommendations selected by each society is not clearly explained. On the other, while some scientific societies clearly define the motives and criteria for their selection, others do so very superficially. In other countries, similar projects have been developed, some of them with another standpoint. The “Too much medicine” program promoted by the British Medical Journal has analyzed the resources wasted for unnecessary interventions, while tackling the issue of overdiagnosis.⁴ This topic goes beyond the realm of this Editorial, although it has motivated several international “Preventing overdiagnosis” conferences. If we focus on Spain, we see that a Spanish autonomous community has promoted an initiative to reduce unnecessary interventions (“Essencial” Project of the Agència de Qualitat i Avaluació Sanitàries de Catalunya [AQuAS]).⁵ Moreover, in April 2013, based on a proposal by the Spanish Society of Internal Medicine, the Healthcare Ministry initiated the project “Commitment to Quality of the Scientific Societies in Spain”, with an approach that is very similar to the American project as it involves the medical societies. To date, 48 societies have participated, and their recommendations have been published on the Healthcare Ministry website.⁶

The Spanish Association of Surgeons has answered this call and designed a strategy to identify experts, suggest and select “Do not do” proposals with a methodology that is described in detail in this issue of Cirugía Española.⁷ The final recommendations are: (a) do not perform cholecystectomy in patients with asymptomatic cholelithiasis; (b) do not prolong urinary catheterization for more than 48 h; (c) do not prolong antibiotic prophylaxis for more than 24 h after a surgical procedure; (d) do not use antibiotic prophylaxis in clean, uncomplicated, non-prosthetic surgery; and (e) do not use postoperative antibiotic treatment after uncomplicated appendicitis.

We must admit that our recommendations differ greatly from the more than 60 recommendations of the National Institute for Health and Care Excellence related with surgical aspects⁸ or the 5 selected by the American College of Surgeons for the “Choosing wisely” project.⁹ However, beyond cost-efficiency considerations, it is evident that the local conditions and the values of the scientific society itself and civil society will determine the choice of one or another type of intervention.

These initiatives to reduce clinical practices that provide little or no value are praiseworthy. Nevertheless, in spite of the strength of the scientific evidence and the more or less palpable complicity of medical societies, we cannot deny that there are serious difficulties for the recommendations to become adopted in general. Sometimes, this is because the evidence itself is disputable due to the selection biases of the studies analyzed. In other instances, it is difficult to adapt clinical practice guidelines to the circumstances of each patient. Lastly, there may be other influential factors involved in the clinical decision-making process, such as the industry or tradition. I believe that these lists of clinical practices that provide little value are valuable instruments for improving clinical efficacy. Nonetheless, it is also necessary to define goals and propose a strategy to reach them, as we do not want the results to be limited.