How to avoid unnecessary interventions
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* Fiona Godlee

Continuing our theme that less medicine is more (*BMJ* 2009;338:b2561, doi:[10.1136/bmj.b2561](https://www.bmj.com/lookup/doi/10.1136/bmj.b2561)), several articles in this week’s journal seek to help doctors cut rates of unnecessary intervention. Nick Francis and colleagues have evaluated a simple way to reduce reconsulting and prescribing of antibiotics in children with upper respiratory tract infection: an eight page, evidence based booklet used during the consultation and taken home afterwards (doi:[10.1136/bmj.b2885](https://www.bmj.com/lookup/doi/10.1136/bmj.b2885)). GPs were trained to use the booklet, and children with suspected pneumonia, asthma, or serious concomitant illness were excluded. Parents who received the booklet were less likely to feel the need to consult their GP again under similar circumstances but were equally satisfied with the care they had received.

Deciding who needs treatment or tests and who doesn’t is one of medicine’s great arts. Clinical judgment will always be needed, but clinical prediction rules can help. As part of our series on diagnosis in general practice, Gavin Falk and Tom Fahey outline some of the limitations of clinical prediction rules (doi:[10.1136/bmj.b2899](https://www.bmj.com/lookup/doi/10.1136/bmj.b2899)), and Dan Mayer explains how to apply one of the best established set of rules, the Ottawa ankle rules (doi:[10.1136/bmj.b2901](https://www.bmj.com/lookup/doi/10.1136/bmj.b2901)). These have been shown in several studies to safely reduce the number of people undergoing radiography for ankle and foot injuries, so it’s surprising to hear that their use in emergency departments is patchy.

Taryn Bessen and colleagues sought to increase use of the Ottawa ankle rules in two hospitals in Adelaide. They put in place several quality improvement measures, including interviewing staff, identifying champions and opinion leaders, and introducing a new x ray request form (doi:[10.1136/bmj.b3056](https://www.bmj.com/lookup/doi/10.1136/bmj.b3056)). Their before and after study showed a substantial increase in the use of the rules but only a modest fall in rates of radiography. It turns out that eliminating an established behaviour is far harder than adding a new one.

In his editorial, Richard Thompson wonders if we expect too much from this sort of approach to implementing complex interventions (doi:[10.1136/bmj.b3124](https://www.bmj.com/lookup/doi/10.1136/bmj.b3124)). Although drug treatments tend to have a stronger evidence base and are easier to implement, they may have only a weak effect in terms of numbers needed to treat. Complex organisational interventions, such as improving uptake of evidence based rules, are far harder to evaluate, but this doesn’t mean they’re less important.

Avoiding unnecessary intervention makes sense for patients because almost all treatments and tests have the potential to do harm. It also makes sense for health care, especially in times of financial constraint. Nigel Hawkes says we’re in for a shock as the financial crisis hits the NHS (doi:[10.1136/bmj.b3251](https://www.bmj.com/lookup/doi/10.1136/bmj.b3251)). With zero growth from 2011 and an ageing population, “to maintain services the NHS has to do something it has never managed: a sustained increase in productivity over the best part of a decade, at unprecedented rates.” Muir Gray thinks the solution for post-crunch health care lies in the medical profession taking a radical stance, demanding better value, lower carbon use, and a 5% reduction in salaries and pensions of its senior members (doi:[10.1136/bmj.b3237](https://www.bmj.com/lookup/doi/10.1136/bmj.b3237)). Now there’s a thought.

## Notes

**Cite this as:** *BMJ* 2009;339:b3304