Wednesday, 28 October 2015

ClinicSpeak: is it time to ditch regular follow-up visits with your neurologist?

What is the value of regular visits  to your neurologist if you are well? #ClinicSpeak #MSBlog #MSResearch

"How valuable are your 6-monthly, annual, or regular neurological appointments in MS? In the past I would have said very valuable as they allowed us, the neurological team, to interrogate you and identify MS-related problems early and manage them before they cause too many problems. In addition, we would use these sessions to educate you about what to expect. However, with the adoption of early effective treatment we are seeing more, and more, of our patients rendered NEDA with very few problems, and an increasing number of patients with no problems at all. Yes, no problems at all; the secret to this is early treatment. If you wait to accumulate damage and lose brain reserve you are then primed for future problems such as the early development of progressive disease."

"I am beginning to realise that seeing patients that are rendered 'well' by effective early treatment is simply consuming valuable clinical and personal time, that could be better used seeing other patients. The debate we are having about how frequently we see these patients is captured in the wider debate on whether or not the annual physical examination in the general population is cost effective and worth doing. The perspective article below, just published the New England Journal of Medicine, captures the relevant issues very well."

"I am not saying we should not see our 'well' patients, but we should put in place systems that prevent unnecessary hospital or clinic visits. Patients on DMTs need monitoring, i.e. periodic blood and urine tests, annual MRI scans and a battery of PROMS (patient-related outcome measures) to monitor the impact of their disease on their functioning. What is needed is for the results of this monitoring to be fed back to them in a timely manner and they only need to see a neurologist if there are problems with their results."

"Would you be prepared to sign-up to a MS service that provides automated monitoring, asynchronous communication, or feedback, of your results with an option of only seeing your MS clinical nurse specialist or neurologist if problems are identified?"



Mehrotra & Prochazka. Improving Value in Health Care — Against the Annual Physical. N Engl J Med 2015; 373:1485-1487.

Excerpts:

..... The past few decades have seen numerous calls to eliminate the annual physical examination. In 1979, the Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practised almost ritualistically for several decades in North America, be abandoned.” In 2013, as part of the Choosing Wisely campaign, the Society of General Internal Medicine recommended against annual preventive examinations in asymptomatic patients.....

.... This ongoing practice is not surprising, since surveys reveal that the majority of both patients and physicians are strong proponents of the annual physical. In the face of this disconnect between expert recommendations and real-world practice, how do we move forward?..

..... both randomized trials and observational studies showed that annual physicals do not reduce morbidity or mortality, though they may be associated with reduced patient worry and increased use of preventive care.....

..... the annual physical may actually be harmful. Some aspects of traditional annual physicals, such as the comprehensive physical exam (which might, for example, detect thyroid nodules) and routine tests (such as urinalysis), have low specificity, which means that most positive results in asymptomatic patients will be false positives......

..... Reducing the use of annual physicals could also save money and time.....

......  Many new health care delivery models such as accountable care organizations and primary care medical homes are built on established patient–physician relationships. With that need in mind, these “primary care maintenance” visits could be limited to the minority of patients who have not seen a physician for a given period, perhaps 3 years, or who are switching to a new primary care provider.....

..... Eliminating the annual physical might appear contradictory to our health care system's increased attention to prevention.....

7 comments:

  1. Hi,
    Seems there's an error on the form. I can answer nothing but 0 to the question : 'On average how often do you see your MS team".

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  2. I'd be fine with that. My nurse asked me recently if I wanted to see my neuro as planned, or if I was happy to wait until my next dose of treatment. I said I'd wait. No need to see him as I'm well, plus I'm confident the support would be there at a later date should I need it. Having his email helps too :-) for me it's a case of knowing there's back up.

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  3. delighted to know that DMT's are changing what you see at the clinic :)

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  4. Do you have annual MRIs for at St Barts for those on DMTs? This is certainly not offered at other NHS hospitals

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  5. Regarding annual physical examination. I don't have these and i'm in the UK.

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