Breathing Issues are Often Under-tested, Over-treated

Republished from Toronto Star's Doctors' Notes

The heat and humidity of summer causes lots of breathing problems, like asthma flare-ups and aggravation of bronchitis. But sometimes doctors diagnose asthma without formal testing, and all too often we give out antibiotics that can’t help. Overtreatment can sometimes be as bad as undertreatment.

It has been demonstrated repeatedly, across diseases and in many countries, that anywhere from 30 per cent to 45 per cent of patients don’t get the care they ought to receive (i.e. what is recommended in medical guidelines), and surprisingly even more — 20 per cent to 30 per cent of patients — receive care that is unnecessary, or even potentially harmful.

It’s important to recognize that doctors, like all humans, are creatures of habit. Although we may all strive to offer our patients the very best possible care, with more than 75 new research studies published every single day, most of us struggle to filter, prioritize and ultimately integrate the latest medical knowledge into our practices.

To this end, the “Choosing Wisely” movement, led by University of Toronto faculty members, develops “Top 5” lists of tests and treatments that are still commonly used, but are not supported by medical evidence and/or could expose patients to unnecessary harm. These lists are meant to challenge existing norms and to encourage practitioners and patients to engage in conversations about whether certain tests and treatments are truly necessary. Last month, Choosing Wisely came out with recommendations for respiratory medicine.

The list is largely focused on common conditions, where the impacts of overtreatment are the most far-reaching. Two of the recommendations target unnecessary prescriptions for inhaler medications — one for patients suspected of having chronic obstructive pulmonary disease (COPD, but often called emphysema or chronic bronchitis), which affects one in four individuals over the age of 35; and one for asthma, which affects up to 15 per cent of Canadians.

Both recommendations call on physicians not to prescribe medications unless and until they have confirmed the diagnosis with a formal breathing test. Although it would seem intuitive to test before treating, these conditions are often diagnosed and treated based on symptoms alone, partly because testing is not always readily available (especially within a short turnaround time). On the flip side, many other conditions can fool us by mimicking the symptoms of COPD or asthma. This was proven in a recent large Canadian study which showed that one-third of patients who had been told they had asthma by their physician did not have it when formally tested.

So if you have been told that you have either COPD or asthma, ask your doctor if formal testing can be arranged, especially before starting treatment.

Over-prescribing antibiotics is also a problem for people with asthma, bronchitis or COPD. Most adult infections that trigger a cough are caused by viruses as opposed to bacteria — which means antibiotics won’t help, even if the cough has lasted for more than a week. In fact, the average duration of cough caused by viruses is around 18 days, whereas studies suggest that patients expect the cough to resolve after about a week (which is often when they visit their doctors and request antibiotics).

With asthma, the most common triggers causing a flare-up (allergens, smoke, pollution or viruses) won’t be helped by antibiotics. Bacterial infections are a very rare cause of asthma flares. Although it may seem innocuous to “try” antibiotics, aside from costs, antibiotic use is not without potential harms, including allergic reactions and the emergence of bacterial resistance.

If you have an infectious cough, or if your asthma is flaring, resist the temptation to ask your doctor for antibiotics. And if you’re being offered antibiotics, ask if they’re truly necessary.

As medical science increasingly challenges many of our commonly held beliefs and practices, both doctors and patients will need constant reminders that in health care, as in life, more does not always mean better (and often means worse). I hope this will act as one of those reminders, and as a starting point for discussions between patients and their doctors.

Dr. Samir Gupta is a respirologist at St. Michael’s Hospital and an assistant professor in the Department of Medicine at U of T. He is chair of the Canadian Thoracic Society Choosing Wisely Task Force.