EHS-COVID (401) Quality (32) Overinvestigation and overtreatment of COVID-19

12 June, 2021

Dear HIFA colleagues,

Here is another perceptive commentary from Soumyadeep Bhaumik (HIFA country representative (India) and HIFA Evidence working group member) and colleagues.

He explores the links between COVID-19 and 'low-value care' in India, with particular reference to 'irresponsible' overinvestigation and overtreatment - among those who can afford it, at the expense of those who cannot.

I invite others from India and worldwide to comment on what is happening in your country.

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Low-value medical care in the pandemic—is this what the doctor ordered

Lancet Global Health 2021

Soumyadeep Bhaumik et al.

Published:June 02, 2021 DOI: https://doi.org/10.1016/S2214-109X(21)00252-7

The humanitarian crisis India faces in the second wave of COVID-19—the rapid surge of cases, the collapsing health system, and the death and despair—are being documented in real time. However, the large-scale practice of low-to-minimal value care and its consequences have escaped notice.

A majority of those with COVID-19 disease have mild-to-moderate symptoms and are managed by qualified doctors out of hospital. A typical prescription for COVID-19 in India includes azithromycin, doxycycline, ivermectin, hydroxychloroquine, vitamin C, vitamin D, zinc, acetylcysteine, and inhaled budesonide or dexamethasone.2, 3 The antiviral favipiravir became the top selling drug in India in April, 2021,4 despite not being recommended for COVID-19 by any major guidelines. Anticoagulants such as rivaroxaban are prescribed in outpatient settings, even for patients without increased thrombotic risk, against the recommendations of most international expert panels. Broad-spectrum antibiotics are added under the pretext of treating secondary infections.

In India, a battery of diagnostic tests is also being conducted for patients with COVID-19—blood counts, blood sugar, kidney and liver function tests, D-dimer, interleukin-6, procalcitonin, C-reactive protein, ferritin, and lactate dehydrogenase...

High-resolution CT scans of the chest are ordered routinely and repeated frequently...

The complexity of clinical decision making notwithstanding, prescribing low-value therapy that does not provide clinical benefit is never desirable, even less so in the context of a pandemic when resources are scarce...

While millions of Indians struggle to stay alive and healthy and avoid going into poverty during the COVID-19 pandemic, such irresponsible behaviour has enabled others to engage in pandemic profiteering...

There is an urgent need for democratising evidence-informed medicine in India. Clinical guidelines should be based on evidence, responsive to local resources, and include a broad range of stakeholders, including patients and their caregivers. Because medical evidence evolves rapidly, especially during a pandemic, guidelines should also be adaptive in nature, and disseminated in a transparent manner using appropriate tools.

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Neil Pakenham-Walsh, HIFA Coordinator, neil@hifa.org www.hifa.org