Changes: Quaternary prevention

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The quaternary prevention, concept coined by the Belgian general practitioner Marc Jamoulle ^[1], are the action taken to identify patient at risk of overmedicalisation, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable. ^[2]

Quaternary prevention is the set of health activities to mitigate or avoid the consequences of unnecessary or excessive intervention of the health system.^[3]

Social credit that legitimizes medical intervention may be damaged if doctors do not prevent unnecessary medical activity and its consequences. Quaternary prevention should take precedence over any alternative preventive, diagnostic and therapeutic, as is the practice version primun non nocere.^[4]

Concept

			absent	present
Prevention levels ^[4]			Doctor’s side
			Disease
Patient’s side	Illness	absent	Primary prevention (illness absent disease absent)	Secondary prevention (illness absent disease present)
Patient’s side	Illness	present	Quaternary prevention (illness present disease absent)	Tertiary prevention (illness present disease present)

Main idea: to avoid patient overdiagnosis and overtreatment.

Use: During all the episode of care (preclinical and clinical period).

It's the "actions taken to identify patients at risk of overtreatment, to protect them from new medical procedures and ethically acceptable alternative to suggest". The concept is included in WONCA's Dictionary of General and Family Medicine. ^[5]

To do quaternary prevention is to say “no” to many considerably indecent proposals, and to offer prudent and scientific alternatives (“ethics of negation” , “ethics of ignorance sharing”). To do quaternary prevention is to to exchange the fear exploited by healthcare malice for the feeling of knowing that what matters is the quality of life.^[6]

The intent of quaternary prevention is not to eliminate but rather to moderate the medicalization of the daily life, since a part of the aforementioned medicalization is not directly related to the medical intervention and has to do with social, cultural and psychologic reasons. Quaternary prevention is only about avoiding or palliating the medical part of the medicalization of the daily life.

To do quaternary prevention in clinical encounters is to comply with the scientific goal of Medicine, which aims for “the maximum quality with the minimum quantity, as close to the patient as possible”.

“To prevent is better than healing, when preventing is less harmful than healing”. To engage into quaternary prevention is to avoid the unnecessary curative and preventive activities. Every doctor-patient encounter should include quaternary prevention in order to avoid/limit the damage caused by the activity of the health system. To do it is to enforce the old motto primum non nocere.^[7]

Means

1.- Narrative based Medicine

The strongest means to accomplish this is to listen better to our patients. This is what has been termed Narrative based Medicine, which means to adapt the medically possible to the individual needs and wants. What we need is a strong and sustainable relationship with our patients and their trust in our honesty and specific knowledge.^[8]

2.- Evidence-based medicine

The other important means is called Evidence based Medicine. The knowledge of the probable predictive values of diagnostic tests and the probabilities of effect sizes of benefit and harm of therapy and preventive measures give us the opportunity to leave out many useless procedures.

Intervention types

Healthcare professionals must be aware of the consequences of their decisions, and include quaternary prevention interventions in their daily clinical practice with each patient.^[9]

To prevent the cascade effect:

- To prevent the diagnostic cascade

- To prevent the therapeutical cascade

To prevent disease promotion
To prevent medicalization

Activities

Do not mistake risk factor with disease. ^[10], ^[11]
To avoid check ups or unnecessary exams.^[12], ^[13]
To avoid technical interventionism in healthcare.
To avoid scoliosis.
To avoid the pharmacological treatment of hypercholesterolemia in primary prevention.^[14]
To avoid hormone replacement therapy during menopause
To avoid the indiscriminate use of antibiotics (very often unnecessary, with the subsequent unjustified increase of bacterial resistances)
To avoid unnecessary diagnosis of genetic disorders (for example: the promotion of the haemocromatosis screening, of doubtful scientific value, but of undoubted effect in terms of the medicalization of society.^[15]
To avoid the overdiagnosis and overtreatment of the attention deficit hyperactivity disorder (ADHD).^[16]
To elaborate validated diagnostic and therapeutic protocols that are effective in the prevention of the renal injury in the minority of patients with “complicated” pielic ectasia, and that avoid the excessive amount of intervention in the majority of the patients with “simple” pielic ectasia.^[17]

References

External links

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[1] Jamoulle M. Information et informatisation en médecine générale. In: Berleur J, Labet-Maris Cl, Poswick RF, Valenduc G, Van Bastelaer Ph. Les informa-g-iciens. Namur (Belgique): Presses Universitaires de Namur; 1986. p.193-209.

[2] Jamoulle M. About prevention; the Quaternary prevention. UCL. 2008

[3] Gervás J. La prevención cuaternaria. OMC. 2004;(95):8.

[Kuehlein-4] 4.0 ^4.1 Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoule M. Quaternary prevention: a task of the general practitioner. PrimaryCare. 2010; 10(18): 350-4.

[5] Bentzen N, editor. WONCA Dictionary of general/family practice. Copenhagen: Maanedskift Lager; 2003.

[6] Gérvas J. Malicia sanitaria y prevención cuaternaria. Gac Med Bilbao. 2007; 104:93-6

[7] Gérvas J. Prevención cuaternaria. Acta Sanitaria. 2011/01/10.

[8] Greenhalgh T, Hurwitz B (ed.). Narrative based Medicine – Dialogue and Discourse in Clinical Practice. London: BMJ Books; 1998.

[9] Gérvas J. ¿El trabajo diario? ¡Basado en la prevención cuaternaria!. Boletín REAP. 2007; 4(1):6-7.

[10] Gérvas J. Pérez Fernández M. Uso y abuso del poder médico para definir enfermedad y factor de riesgo, en relación con la prevención cuaternaria. Gac Sanit. 2006; 20(Supl 3):66-71.

[11] Miguel F. Factores de riesgo: una nada inocente ambigüedad en el corazón de la medicina actual. Aten Primaria. 1998; 22:585-95.

[12] Gérvas J. Chequeos. Acta Sanitaria. 2010/09/06.

[13] Segura Benedicto A. Cribado de enfermedades y factores de riesgo en personas sanas. El lado oscuro de la fuerza. Humanitas. 2008 sept; (31):1-17.

[14] Gérvas J. Moderación en la actividad médica preventiva y curativa. Cuatro ejemplos de necesidad de prevención cuaternaria en España. Gac Sanit. 2006; 20(Supl 1):127-34.

[15] Gérvas J, Pérez Fernández M. Genética y prevención cuaternaria. El ejemplo de la hemocromatosis. Aten Primaria. 2003; 32:158-62.

[16] Morell Sixto ME, Martínez González C, Quintana Gómez JL. Disease mongering, el lucrativo negocio de la promoción de enfermedades. Rev Pediatr Aten Primaria. 2009; 11(43):491-512.

[17] González de Dios J, Ochoa Sangrador C. Ectasia piélica perinatal, efecto cascada y prevención cuaternaria. An Pediatr (Barc). 2005; 63(1):83-5.

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 * [[Juan Gérvas]]
 * [[Medical ethics]]
+* [[Medical error]]
 * [[Medicalization]]
 * [[Medicine]]
 * [[Patient safety]]
+* [[Polypharmacy]]
 * [[Preventive medicine]]
 * [[Side effects]]