¿Por qué resulta cada vez más complicado "hacer lo que hay que hacer" y "dejar de hacer lo que no hay que hacer"? Estrategias para revertir las prácticas de bajo valor / Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices

En este trabajo se describen los factores que han propiciado la expansión de las prácticas de bajo valor (PBV) junto con las principales iniciativas para revertirlas. El artículo destaca las estrategias que han demostrado ser más útiles a lo largo de los años, desde la adecuación de la práctica clínica a las recomendaciones “no hacer”, pasando por la prevención cuaternaria y el abordaje de los riesgos asociados al intervencionismo. Revertir las PBV requiere un proceso planificado con un enfoque multifactorial que involucre a los diferentes agentes implicados. Además ha de tener en cuenta las barreras que dificultan la desimplementación de las PBV e incorpore las herramientas que facilitan la adherencia a las recomendaciones “no hacer”. El papel del médico de familia es especialmente relevante en la prevención, detección y desimplementación de las PBV, por su carácter coordinador e integrador de la atención que reciben los pacientes, y porque en el primer nivel asistencial se gestionan y resuelven la mayor parte de las demandas asistenciales.(AU)

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with “do not do” recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to “do not do” recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients’ healthcare, and because most of the citizens’ healthcare demands are managed and resolved at the first level of care.(AU)

[Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices]. / ¿Por qué resulta cada vez más complicado "hacer lo que hay que hacer" y "dejar de hacer lo que no hay que hacer"? Estrategias para revertir las prácticas de bajo valor.

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with "do not do" recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to "do not do" recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients' healthcare, and because most of the citizens' healthcare demands are managed and resolved at the first level of care.

[Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]. / El error diagnóstico y sobrediagnóstico en Atención Primaria. Propuestas para la mejora de la práctica clínica en medicina de familia.

Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.

[Primary care organization in pandemic times]. / Organización de la Atención Primaria en tiempos de pandemia.

The COVID-19 pandemic has forced the adoption of drastic changes in primary care, modifying the organization and work dynamics previously established. From one day to the next, professionals had to adapt to the new situation to be able to attend cases and contacts tracing, to avoid contagion and to maintain attention to other health problems. At the beginning of the pandemic, professionals had to establish new practices and care circuits in primary care in an improvised way, due to lack of updated guidelines, without adequate means of protection, evaluating their risks and benefits on the fly. We present the main organizational changes in the first level of care and describe, from the point of view of patient safety and the consequences for patients and professionals of the priority care for COVID-19. Finally, we consider how to incorporate the knowledge acquired during the pandemic, analyzing the advantages and disadvantages of the adopted measures to maintain as much as possible a safe, accessible and quality primary care.

[Impact of overdiagnosis and overtreatment on the patient, the health system and society]. / Impacto del sobrediagnóstico y sobretratamiento en el paciente, el sistema sanitario y la sociedad.

The medical activity displays a set of skills aimed at improving the health status of people. In this way, diagnoses are made, choices of tests and treatments are made, and decisions are made about what to do and what not to do that affect the lives of patients. In this article, we propose a reflection on overdiagnosis and overtreatment in relation to the factors that promote it and the impact they have on society, on the functioning of the health system and also directly on patients. Finally, we make some proposals on how to address this overuse considering that primary care is a privileged place to adapt and minimize the impact of the actions of the health system on the health of citizens and reduce the incidents of patient safety linked to the overdiagnosis and inappropriate use of tests and treatments that do not add value to the health of patients.

Impacto del sobrediagnóstico y sobretratamiento en el paciente, el sistema sanitario y la sociedad / Impact of overdiagnosis and overtreatment on the patient, the health system and society

La actividad médica despliega un conjunto de competencias encaminadas a mejorar el estado de salud de las personas. En este camino se realizan diagnósticos, se hacen elecciones de pruebas y tratamientos y se toman decisiones sobre hacer y no hacer que afectan a la vida de los pacientes. En este artículo, proponemos una reflexión ante el sobrediagnóstico y sobretratamiento en relación con los factores que lo promueven y el impacto que tienen en la sociedad, en el funcionamiento del sistema sanitario y también directamente en los pacientes. Finalmente, realizamos unas propuestas de cómo redirigir este exceso considerando que la atención primaria es un lugar privilegiado para actuar en adecuar y minimizar el impacto de las actuaciones del sistema sanitario en la salud de los ciudadanos y reducir los incidentes de seguridad del paciente ligados al sobrediagnóstico y al uso inadecuado de pruebas y tratamientos que no aportan valor a la salud de los pacientes

The medical activity displays a set of skills aimed at improving the health status of people. In this way, diagnoses are made, choices of tests and treatments are made, and decisions are made about what to do and what not to do that affect the lives of patients. In this article, we propose a reflection on overdiagnosis and overtreatment in relation to the factors that promote it and the impact they have on society, on the functioning of the health system and also directly on patients. Finally, we make some proposals on how to address this overuse considering that primary care is a privileged place to adapt and minimize the impact of the actions of the health system on the health of citizens and reduce the incidents of patient safety linked to the overdiagnosis and inappropriate use of tests and treatments that do not add value to the health of patients