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Preventing overdiagnosis: How to stop harming the healthy

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MEDICALISATION
Preventing overdiagnosis: how to stop harming the
healthy
Evidence is mounting that medicine is harming healthy people through ever earlier detection and
ever wider definition of disease.With the announcement of an international conference to improve
understanding of the problem of overdiagnosis, Ray Moynihan, Jenny Doust, and David Henry
examine its causes and explore solutions
Ray Moynihan senior research fellow
1
, Jenny Doust professor of clinical epidemiology
2
, David
Henry chief executive officer
3
1
Bond University, Robina, Queensland, Australia;
2
Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond
University, Australia;
3
Institute for Clinical Evaluative Sciences, Toronto, Canada
Medicine’s much hailed ability to help the sick is fast being
challenged by its propensity to harm the healthy. A burgeoning
scientific literature is fuelling public concerns that too many
people are being overdosed,
1
overtreated,
2
and overdiagnosed.
3
Screening programmes are detecting early cancers that will
never cause symptoms or death,
4
sensitive diagnostic
technologies identify “abnormalities” so tiny they will remain
benign,
5
while widening disease definitions mean people at ever
lower risks receive permanent medical labels and lifelong
treatments that will fail to benefit many of them.
3 6
With
estimates that more than $200bn (£128bn; €160bn) may be
wasted on unnecessary treatment every year in the United
States,
7
the cumulative burden from overdiagnosis poses a
significant threat to human health.
Narrowly defined, overdiagnosis occurs when people without
symptoms are diagnosed with a disease that ultimately will not
cause them to experience symptoms or early death.
3
More
broadly defined, overdiagnosis refers to the related problems
of overmedicalisation and subsequent overtreatment, diagnosis
creep, shifting thresholds, and disease mongering, all processes
helping to reclassify healthy people with mild problems or at
low risk as sick.
8
The downsides of overdiagnosis include the negative effects of
unnecessary labelling, the harms of unneeded tests and therapies,
and the opportunity cost of wasted resources that could be better
used to treat or prevent genuine illness. The challenge is to
articulate the nature and extent of the problem more widely,
identify the patterns and drivers, and develop a suite of responses
from the clinical to the cultural.
At the clinical level, a key aim is to better discriminate between
benign “abnormalities” and those that will go on to cause harm.
In terms of education and raising awareness among both the
public and professionals, more honest information is needed
about the risk of overdiagnosis, particularly related to screening.
More deeply, mounting evidence that we’re harming healthy
people may force a questioning of our faith in ever-earlier
detection, a renewal of the process of disease definition, and a
fundamental shift in the systemic incentives driving dangerous
excess.
Next year, an international scientific conference called
Preventing Overdiagnosis aims to deepen understanding and
awareness of the problem and its prevention. The conference
will take place on 10-12 September 2013 in the United States,
hosted by the Dartmouth Institute for Health Policy and Clinical
Practice in partnership with the BMJ, the leading US consumer
organisation Consumer Reports, and Bond University. The
conference is timely, as growing concern about overdiagnosis
is giving way to concerted action. The Archives of Internal
Medicine’s feature “Less is More” now regularly augments the
evidence base,
9
high level health policy groups in Europe are
debating ways to tackle excess,
10
and the recently launched
Choosing Wisely campaign warns about dozens of potentially
unnecessary tests and treatments across nine specialties.
11
Many factors—including the best of intentions—are driving
overdiagnosis, but a key contributor is advances in technology.
The literature suggests several broad and related pathways to
overdiagnosis: screening detected overdiagnosis in people
without symptoms; overdiagnosis resulting from use of
increasingly sensitive tests in those with symptoms;
Correspondence to: R Moynihan raymoynihan@bond.edu.au
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Feature
FEATURE
overdiagnosis made incidentally—“incidentalomas”; and
overdiagnosis resulting from excessively widened disease
definitions. These different pathways are not mutually exclusive,
and a more rigorous classification of the different forms of
overdiagnosis will be a focus of discussion at the 2013 scientific
conference.
Screening detected overdiagnosis
This pathway to overdiagnosis occurs when a screening
programme detects disease in a person without symptoms but
the disease is in a form that will never cause that person
symptoms or early death. Sometimes this form of disease is
called pseudodisease. Contrary to popular notions that cancers
are universally harmful and ultimately fatal, some cancers can
regress, fail to progress, or grow so slowly that they will not
cause harm before the individual dies from other causes.
5
As
we will discuss below, there is now strong evidence from
randomised trials and other studies comparing screened and
unscreened populations that an important proportion of the
cancer detected through some popular screening programmes
may be pseudodisease.
4 12
Evidence from autopsy studies
suggests a large reservoir of subclinical disease in the general
population, including prostate, breast, and thyroid cancer, the
bulk of which will never harm.
12
Similarly, screening the hearts
of people without symptoms or at low risk may also lead to
overdiagnosis of coronary atherosclerosis and subsequent
unnecessary interventions.
13
Our understanding of the nature
and extent of overdiagnosis and the amount of pseudodisease
detected by screening remains limited but is evolving, and as
Woolfe and Harris observed recently in JAMA, “concern about
overdiagnosis is justified.”
14
Increasingly sensitive tests
People presenting to doctors with symptoms can also be
overdiagnosed because changes in diagnostic technologies or
methods have enabled the identification of less severe forms of
diseases or disorders. It is becoming clearer that a substantial
proportion of these earlier “abnormalities” will never progress,
raising awkward questions about exactly when to use diagnostic
labels and therapeutic approaches traditionally deployed against
much more serious forms of disease.
Incidentalomas
Diagnostic scanning of the abdomen, pelvis, chest, head, and
neck can reveal “incidental findings” in up to 40% of individuals
being tested for other reasons.
15
Some of these are tumours, and
most of these “incidentalomas” are benign. A very small number
of people will benefit from early detection of an incidental
malignant tumour, while others will suffer the anxiety and
adverse effects of further investigation and treatment of an
“abnormality” that would never have harmed them. As others
have shown, the rapidly rising incidence for some cancers, set
against relatively stable death rates, is a phenomenon suggestive
of widespread overdiagnosis, whether from screening or the
detection of incidentalomas (figure).
12
Excessively widened definitions
Another pathway to overdiagnosis is through disease boundaries
being widened and treatment thresholds lowered to a point where
a medical label and subsequent therapy may cause people more
harm than good. Changing diagnostic criteria for many
conditions are routinely increasing the numbers of people
defined as sick,
16
causing virtually the entire older adult
population to be classified as having at least one chronic
condition.
17
This widening has happened both with asymptomatic
conditions that carry a risk of an adverse event, such as
osteoporosis, where treatments may do more harm than good
for those at very low risk of fracture,
18
and for behavioural
conditions such as female sexual dysfunction, where common
difficulties have been reclassified as dysfunctions.
19
Such changes in diagnostic criteria are commonly made by
panels of health professionals with financial ties to companies
that benefit directly from any expansion of the patient pool.
20
As definitions broaden and thresholds fall, people with smaller
risks or milder problems are labelled, which means the potential
benefits of treatment decline, raising the possibility that harms
will outweigh benefits. As Welch and colleagues estimated in
their 2011 book Overdiagnosed,
3
many people diagnosed and
treated long term for near-normal cholesterol concentration or
near-normal osteoporosis may be “overdiagnosed,” in the sense
that they would never have experienced the events their
treatments are designed to prevent.
A related form of overdiagnosis occurs when people are
diagnosed outside of already widened diagnostic criteria, as can
occur when inappropriate manufacturers’ norms exaggerate the
incidence of abnormality,
21
when diagnostic methods wrongly
label random or normal fluctuations in biomarkers as true
abnormalities,
22
or when important qualifiers are left out of the
process of diagnosis.
23
Examples of overdiagnosis
The growing evidence on overdiagnosis suggests the problem
may exist to varying extents across many conditions (box 1),
including those for which underdiagnosis may simultaneously
be a feature. For some conditions, the evidence remains tentative
and speculative, for others it has become much more robust.
Breast cancer
Arguably the strongest evidence of overdiagnosis comes from
studies of screening detected breast cancers, though estimates
of its extent are wide ranging. A 2007 systematic review in
Lancet Oncology found the proportion of overdiagnosis of
invasive breast cancer among women in their 50s ranged from
1.7% to 54%.
24
An Australian study estimated the rate was at
least 30%,
25
while a Norwegian study calculated 15-25%.
26
A
2009 systematic review in the BMJ concluded up to one third
of all screening detected cancers may be overdiagnosed.
4
However, even with strong evidence from population based
studies, it is currently impossible to discriminate between
cancers that will harm and those that will not.
Thyroid cancer
While the chances of tests detecting a thyroid “abnormality”
are high, the risk it will ever cause harm is low.
3 27
Analysis of
rising incidence shows many of the newly diagnosed thyroid
cancers are the smaller and less aggressive forms not requiring
treatment,
28
which itself carries the risk of damaged nerves and
long term medication.
3
Gestational diabetes
A 2010 revision of the criteria defining gestational diabetes
recommended a dramatic lowering of the diagnostic threshold,
more than doubling the number of pregnant woman classified
to almost 18%.
29
Proponents argue universal screening with the
new definition will reduce health problems, including babies
being “large for gestational age.”
29
Critics, however, are calling
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BMJ 2012;344:e3502 doi: 10.1136/bmj.e3502 (Published 29 May 2012) Page 2 of 6
FEATURE
Box 1: Problems of overdiagnosis
Asthma—Canadian study suggests 30% of people with diagnosis may not have asthma, and 66% of those may not require medications
37
Attention deficit hyperactivity disorder—Widened definitions have led to concerns about overdiagnosis; boys born at the end of the
school year have 30% higher chance of diagnosis and 40% higher chance of medication than those born at the beginning of the year
46
Breast cancer—Systematic review suggests up to a third of screening detected cancers may be overdiagnosed
4
Chronic kidney disease—Controversial definition classifies 1 in 10 as having disease; concerns about overdiagnosis of many elderly
people
23
Gestational diabetes—Expanded definition classifies almost 1 in 5 pregnant women
31
High blood pressure—Systematic review suggests possibility of substantial overdiagnosis
22
High cholesterol—Estimates that up to 80% of people with near normal cholesterol treated for life may be overdiagnosed
3
Lung cancer—25% or more of screening detected lung cancers may be overdiagnosed
56
Osteoporosis—Expanded definitions may mean many treated low risk women experience net harm
18
Prostate cancer—Risk that a cancer detected by prostate specific antigen testing is overdiagnosed may be over 60%
12
Pulmonary embolism—Increased diagnostic sensitivity leads to detection of small emboli. Many may not require anticoagulant treatment
39
Thyroid cancer—Much of the observed increase in incidence may be overdiagnosis
28
for an urgent debate before the new expanded definition is more
widely adopted, because they fear many women may be
overmedicalised and overdiagnosed, that the screening test has
poor reproducibility for mild cases, the evidence of benefit for
the newly diagnosed pregnant women is weak, and the benefit
modest at best.
30 31
Chronic kidney disease
More than 10% of adults in the United States are now classified
as having some form of chronic kidney disease.
32
A working
definition launched as part of new clinical guidelines
33
asserts
that an estimated glomerular filtration rate (eGFR) below 60
ml/min/1.73m
2
and sustained for three months or longer is
deemed abnormal, a decision critics argue automatically creates
the potential for overdiagnosis, particularly among elderly
people.
34
According to Winearls and Glassock in an article last year the
new classification system is “like a fishing trawler” and
“captures many more innocent subjects than it should.”
23
They
estimate that up to one third of people over 65 may meet the
new criteria, yet of these, fewer than 1 in 1000 will develop end
stage renal disease each year. They also point to major problems
with the reliability and consistency of the eGFR test and express
concern many older people are being labelled on the basis of a
single and potentially inaccurate laboratory measure. Elsewhere
they have argued that “the majority of those held to have CKD
[chronic kidney disease] have no identifiable kidney disease”
and they’ve highlighted attempts by some organisations to move
away from the controversial new definition, raise the threshold
for diagnosis, and dramatically reduce prevalence.
35
Responding
to criticisms, proponents have defended the new definition as
being “clear, simple, and useful.”
36
Asthma
Although asthma can be severe and may be underdiagnosed and
undertreated, some studies suggest that there may also be
substantial overdiagnosis. One large study in 2008 found that
almost 30% of people diagnosed as having asthma did not have
the condition, and almost 66% of those did not need drugs or
asthma care during six months of follow-up.
37
The authors
concluded, “A substantial proportion of people . . . may be
overdiagnosed with asthma and may be prescribed asthma
medications unnecessarily.” In the same year a Dutch study
found that of 1100 patients using inhaled corticosteroids, 30%
may have been using the drugs without any clear indications.
38
Pulmonary embolism
Doctors think of pulmonary embolism as a “not to be missed”
diagnosis, because failure to detect it can have catastrophic
consequences. Historically it was diagnosed only when the
blockage was large enough to cause infarction of part of the
lung or haemodynamic instability. In such patients, treatment
with an anticoagulant or a thrombolytic agent was considered
mandatory. Now, however, computed tomography (CT)
pulmonary angiography can detect smaller clots, and there is
uncertainty about whether treatment is always necessary.
39
Analysing trends before and after the widespread introduction
of CT pulmonary angiography, Weiner and colleagues suggested
that the almost doubling in incidence “reflects an epidemic of
diagnostic testing that has created overdiagnosis,” with much
of the increase consisting of “clinically unimportant” cases that
“would not have been fatal even if left undiagnosed and
untreated.”
40
An observational study is investigating the safety
of not treating people with very small blood clots.
41
Attention deficit hyperactivity disorder
Much has been written about expanding diagnostic definitions
within mental illness and concerns about the dangers of
overtreatment.
42
Debate has intensified with suggestions that
current processes for defining disease may be contributing to
the widespread overdiagnosis of conditions such as bipolar,
autistic disorder, and attention deficit hyperactivity disorders.
43 44
One focus of concern is the possible overdiagnosis of children,
who have no say in the appropriateness of a label that can
permanently change their lives. This is particularly salient with
attention deficit hyperactivity disorder.
45
A recent study of
almost a million Canadian children found boys born in
December (typically the youngest in their year) had a 30%
higher chance of diagnosis and 40% higher chance of receiving
medication than those born in January, with the authors
concluding their findings “raise concerns about the potential
harms of overdiagnosis and overprescribing.”
46
Drivers of overdiagnosis
The forces driving overdiagnosis are embedded deep within the
culture of medicine and wider society, underscoring the
challenges facing any attempt to combat them (box 2). A key
driver is technological change itself. As Black described in
1998, the ability to detect smaller abnormalities axiomatically
tends to increase the prevalence of any given disease.
5
In turn
this leads to overestimation of the benefits of therapies, as milder
forms of the disease are treated and improvements in health are
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FEATURE
wrongly ascribed to treatment success, creating a “false
feedback” loop fuelling a “cycle of increasing testing and
treatment, which may eventually cause more harm than benefit.”
5
The industries that benefit from expanded markets for tests and
treatments hold widereaching influence within the medical
profession and wider society, through financial ties with
professional and patient groups and funding of
direct-to-consumer advertising, research foundations, disease
awareness campaigns, and medical education.
8
Most importantly,
the members of panels that write disease definitions or treatment
thresholds often have financial ties to companies that stand to
gain from expanded markets.
20
Similarly, health professionals
and their associations may have an interest in maximising the
patient pool within their specialty, and self-referrals by clinicians
to diagnostic or therapeutic technologies in which they have a
commercial interest may also drive unnecessary diagnosis.
Avoidance of litigation and the psychology of regret is another
obvious driver as professionals can be punished for missing the
early signs of disease yet don’t generally face sanctions for
overdiagnosing. Quality measures focused on doing more may
also encourage overdiagnosis in order to meet targets for
remuneration incentives.
47
An intuitive belief in early detection, fed by deep faith in
medical technology is arguably at the heart of the problem of
overdiagnosis. Increasingly we’ve come to regard simply being
“at risk” of future disease as being a disease in its own right.
Starting with treatment of high blood pressure in the middle of
the 20th century,
48
increasing proportions of the healthy
population have been medicalised and medicated for growing
numbers of symptomless conditions, based solely on their
estimated risk of future events. Although the approach has
reduced suffering and extended life for many, for those
overdiagnosed it has needlessly turned the experience of life
into a tangled web of chronic conditions. The cultural norm that
“more is better” is confirmed by recent evidence suggesting
patient satisfaction flows from increased access to tests and
treatments, even though more care may be associated with
greater harm.
49 50
What can we do about overdiagnosis?
Building on existing knowledge and activity, the 2013
conference on overdiagnosis will provide a forum for learning
more, increasing awareness, and developing ways to prevent
the problem (www.preventingoverdiagnosis.net). Research on
overdiagnosis is now recognised as part of the future scientific
direction of the National Cancer Institute’s division of cancer
prevention in the United States.
51
The 2013 conference hopes
to provide researchers working in this field with the chance to
share and debate methods and further advance research agendas.
As to education, the development of a range of curriculums and
information packages could help raise awareness about the risks
of overdiagnosis, particularly associated with screening.
52
In
association with the BMJ, a series of articles about the potential
for overdiagnosis within specific conditions is being planned.
And at the level of clinical practice new protocols are being
developed to bring more caution in treating incidentalomas.
3
Similarly, some are urging that we consider raising the
thresholds that define “abnormal”—in breast cancer screening,
for example—and evaluate methods of observing changes to
some suspected pathologies over time, rather than intervening
immediately.
53
As we’ve seen, early studies of how to safely
undiagnose or de-prescribe are starting to emerge.
At a policy level, reform of the process of defining disease is
urgently required, with one model coming from the National
Institutes of Health in the United States, where people with
financial or reputational conflicts of interest are disqualified
from panel membership.
20
Dispassionate assessment of evidence
may result in disease definitions being narrowed, as has been
seen with the recent tentative proposals to raise thresholds for
high blood pressure that could demedicalise up to 100 million
people.
54
Processes for defining disease may also benefit from
an attempt to synthesise the evidence from clinical medicine
with literature on the wider social and environmental
determinants of health. Other policy reforms could review the
permanency of some diagnostic labels, address calls for
increased independence in the design and running of scientific
studies,
55
and adjust the structural and legal incentives driving
overdiagnosis.
Concern about overdiagnosis does not preclude awareness that
many people miss out on much needed healthcare. On the
contrary, resources wasted on unnecessary care can be much
better spent treating and preventing genuine illness. The
challenge is to work out which is which, and to produce and
disseminate evidence to help us all make more informed
decisions about when a diagnosis might do us more good than
harm.
We thank the participants at the April 2012 Coolangatta planning meeting
on overdiagnosis: Paul Glasziou, Kirsten McCaffery, Melissa Sweet,
Hilda Bastion, Andrew Wilson, Ian Scott, Suzanne Hill, Alexandra Barratt,
Steve Woloshin, Lisa Schwartz, Fiona Godlee, and Rae Thomas. We
also thank Julia Lowe.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: JD is supported
by NHMRC project grant 511217; they have no financial relationships
with any organisations that might have an interest in the submitted work
in the previous three years; all authors were at the April 2012 planning
meeting for the 2013 conference and RM is undertaking a PhD on
overdiagnosis.
Provenance and peer review: Commissioned; externally peer reviewed.
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Cite this as: BMJ 2012;344:e3502
© BMJ Publishing Group Ltd 2012
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BMJ 2012;344:e3502 doi: 10.1136/bmj.e3502 (Published 29 May 2012) Page 5 of 6
FEATURE
Figure
Rates of new diagnosis and death for five types of cancer in the US, 1975-2005. Adapted from Welch and Black
12
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FEATURE
... The flourishing of HSPs has taken place within the context of three broader developments occurring at the global and local level: (1) the corporatisation of healthcare with its emphasis on cost efficiency; (2) an increasing shift in focus from treatment to prevention amidst an increasing burden from noncommunicable diseases on healthcare systems; (3) and, advances in technology that detect "abnormalities" at increasingly lower thresholds (which may not otherwise cause morbidity or death) [17][18][19][20]. The value proposition of HSPs seems to dovetail with these developments as they offer an expanding pool of would-be "patients" an opportunity for early diagnosis and treatment, and serve as a new market which healthcare organisations can tap on to generate revenue. ...
... Overdiagnosis is often accompanied by overtreatment; because "disease" was detected, individuals received treatment that may not have been needed, inadvertently placing them at risk of harm from these treatments. Overtreatment also results in a waste of resources that could arguably be better used for genuine health needs [20,32]. ...
... Most providers analysed offered non-recommended screening (12 and 11 providers offered category 2 and 3 tests, respectively)-the use of tests lacking evidence for population screening increases the exposure of individuals to a litany of harms such as false positives or negatives, need for further investigations (that may be invasive), overdiagnosis and overtreatment, psychological distress and financial costs [3,20,32,33]. However, none of the providers' websites communicated these harms. ...
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Background Health screening is undertaken to identify individuals who are deemed at higher risk of disease for further diagnostic testing so that they may possibly benefit from interventions to modify the natural course of disease. In Singapore, screening tests are widely available in the form of a package, which bundles multiple tests in one session and commonly includes non-recommended tests. There are various ethical issues associated with such testing as they may not be clinically appropriate and can result in more harm than benefit. This article describes the practice of health screening packages, identifies the ethical issues arising from such packages and discusses the implications of these ethical issues on policy and practice of screening in Singapore. Methods A content analysis of the websites of providers offering general health screening packages to individuals was conducted. A total of 14 health screening package providers were analysed for how packages were conducted and promoted, how clinically appropriate screening tests were, and the price range and composition of screening packages. A normative ethical analysis based on the four principles approach of beneficence, non-maleficence, autonomy and justice in biomedical ethics was used. Results Twelve of the 14 providers included non-recommended tests such as tumour markers, treadmill stress tests and MRI scans in their general health screening packages. Package prices ranged from S$26 to S$10,561, with providers charging higher when more tests were included. Health screening packages were broadly conducted in three stages: (1) the offer and selection of a health screening package; (2) medical assessment and performance of screening tests; (3) a post-screening review. While material provided by all providers was factual, there was no information on the potential risks or harms of screening. Conclusion Several ethical issues were identified that should be addressed with regard to health screening packages in Singapore. A key issue was the information gap between providers and patients, which may result in patients undergoing inappropriate testing that may be more harmful than beneficial. Health screening packages can stimulate unnecessary demand for healthcare and contribute to an inequitable distribution of healthcare resources.
... raised about the resource utilisation and health care costs associated with these scans [2][3][4][5] and the potential harms of radiation exposure, especially in young patients [6,7]. There may also be adverse consequences of overdiagnosis, i.e., diagnosis and subsequent treatment of clinically insignificant disease or issues not related to the health encounter [8,9]. Furthermore, when service capacity is constrained, providing low-value care (interventions where evidence shows they provide no patientcentred benefit) to one patient can delay provision of care to another patient, resulting in indirect harm [10]. ...
Article
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Background Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors’ decisions to order CT of the head or cervical spine. Methods In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. Results In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. Conclusions CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.
... Overdiagnosis is counterintuitive and challenging to both understand and communicate, particularly in light of strong beliefs in the benefits of early detection. [33][34][35] Including more specific case studies and examples of overdiagnosis in future iterations may be helpful in conveying the unintended harms of an unnecessary diagnosis. Both participants and facilitators felt the workshop was too short, with most participants expressing interest in a longer version. ...
Article
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Objectives Although the media can influence public perceptions and utilisation of healthcare, journalists generally receive no routine training in interpreting and reporting on medical research. Given growing evidence about the problems of medical overuse, the need for quality media reporting has become a greater priority. This study aimed to codesign and assess the feasibility of a multicomponent training intervention for journalists in Australia. Design A small pragmatic feasibility study using a pre- and postdesign. Setting 90 min online workshop. Participants Eight journalists currently working in Australia, recruited through the study’s journalist advisor and existing contacts of the researchers. Intervention The training intervention covered a range of topics, including study designs, conflicts of interest, misleading medical statistics, population screening and overdiagnosis. The intervention also provided tools to help journalists with reporting, including a Tip Sheet and list of expert contacts in health and medicine. Preworkshop and postworkshop questionnaires were administered via Qualtrics. Measures Acceptability and feasibility of the intervention, and journalists’ knowledge of overdiagnosis and common issues with health stories. Quantitative results were analysed descriptively using SPSS. Qualitative data were thematically analysed. Results All participants completed preworkshop and postworkshop questionnaires, and 6 completed the 6-week follow-up (75% retention). Feasibility findings suggest the intervention is acceptable and relevant to journalists, with participants indicating the workshop increased confidence with reporting on medical research. We observed increases in knowledge preworkshop to postworkshop for all knowledge measures on overdiagnosis and common issues with media coverage of medicine. Analysis of free-text responses identified several areas for improvement, such as including more examples to aid understanding of the counterintuitive topic of overdiagnosis and more time for discussion. Conclusions Piloting suggested the multicomponent training intervention is acceptable to journalists and provided important feedback and insights to inform a future trial of the intervention’s impact on media coverage of medicine.
... Overdiagnosis might result from (i) increasingly sensitive tests, (ii) incidental findings or (iii) excessively widened definitions of diagnostic criteria (Moynihan et al., 2012). Prominent examples are bone mineral density screening for osteoporosis in younger patients with no risk factors or cholesterol screening among asymptomatic patients. ...
Article
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Reproductive immunology has grown in importance in recent years and has even developed into a discipline of its own within the field of reproductive medicine. Many aspects of reproductive failure such as repeated implantation failure (RIF) or recurrent miscarriages (RM) are meanwhile seen as a consequence of aberrant expression of immunological factors. This is reflected by the increasing number of tests for assessing and quantifying different immune cell types as well as by a wide range of immune therapies offered to a clientele consisting of desperate patients requesting additional “IVF tools”. Firstly, what is still usually disregarded is the enormous plasticity and fluctuation of most immune cells in the genital tract. Second, their still poorly characterized functions in the endometrial cycle, further their partially unknown role in embryo implantation and in establishing a pregnancy. Third, the fact, that one of the fundamental hypotheses of reproductive immunology -of note- the Medawar concept or “Medawar's Paradox of semi-allogeneic graft embryo, is partially based on an erroneous assumption, i.e., the immunologic rejection and tolerance of an embryo. In the present opinion paper, we comment on the diagnostic procedures and therapy approaches for chronic endometritis (CE) within the scope of reproductive medicine.
... Detection of dementia by primary care physicians is low [25], particularly in the early stages of the condition where the symptoms can be difficult to distinguish from normal cognitive ageing and from short-term loss of function secondary to other problems such as depression [3], and also because of the slow progression in the case of the most prevalent type of dementia, Alzheimer's disease [26]. Due to the potential risks of over-diagnosis, clinicians may also be cautious in order to avoid a misdiagnosis of dementia [27]. Dementia is heterogeneous with over 100 sub-types, each of which can have different profiles of cognitive and non-cognitive symptoms, which adds to the difficulties in diagnosing the condition [17]. ...
Article
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Background Many people living with dementia remain undiagnosed, with diagnosis usually occurring long after signs and symptoms are present. A timely diagnosis is important for the wellbeing of the person living with dementia and the family, allowing them to plan and have access to support services sooner. The aim of this study was to identify demographic characteristics and neuropsychiatric symptoms associated with being undiagnosed, which may help clinicians be more aware of signs that could be indicative of early-stage or undetected dementia. Methods This cross-sectional study uses data from waves 1 and 2 (two years apart) of the Cognitive Function and Ageing Studies Wales (CFAS Wales). CFAS Wales participants were included who had a study assessment of dementia, as determined by the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT) algorithm and by expert assessment, and who had had their primary care records checked for a clinical diagnosis of dementia. We identified 19 people with a diagnosis of dementia and 105 people living with undiagnosed dementia, and explored demographic characteristics and the presence or absence of a range of neuropsychiatric symptoms in the undiagnosed population using logistic regression. Results Findings suggest that people living with dementia who have better cognition, have more years of education, or live in more deprived areas are less likely to have a diagnosis. In terms of neuropsychiatric symptoms, depression and sleep problems were associated with being undiagnosed. Apathy was common across all people living with dementia, but those with a diagnosis were more likely to have severe apathy. Conclusions This study has clinical practice implications as the findings may help clinicians be more aware of characteristics and symptoms of people who are undiagnosed or who are at greater risk of remaining undiagnosed, enabling them to be more vigilant in picking up signs of dementia at an earlier stage.
... On the other side, there has been a rising evidence of inappropriate use of 25(OH)D testing generating a heavy burden on healthcare system (2). In general, an inappropriate or unnecessary use of the laboratory test corresponds to the overtesting that may lead to the overdiagnosis causing that people with no signs and symptoms receive a medical condition (3). According to the definition, the overtesting may be detected by screening of 2 the asymptomatic people by the non-recommended test or by performing more testing that is needed to diagnose patients with clinical conditions (4). ...
Article
Introduction: Vitamin D testing is excessively used in clinical practice, despite of the clinical guidelines statements against population screening for vitamin D deficiency. This study aimed to assess an annual number of performed 25-hydroxy vitamin D (25(OH)D) tests that were unsupported by the national guidelines for prevention, detection and therapy of vitamin D deficiency in adults and to calculate associated financial burden for the publicly funded healthcare. Materials and methods: A representative sample of requested 25(OH)D tests in 2018 (N = 474) was formed after selection and randomisation of data set (N = 5298) collected from the laboratory information system database of the Clinical Department for Laboratory Diagnostics, the Clinical Hospital Centre Rijeka. Records were classified in two groups depending on associated medical condition(s) according to the national guidelines. An annual cost of the total and group specific vitamin D testing was calculated on the base of a single test price reimbursed by the Croatian Healthcare Insurance Fund (CHIF). Results: Medical conditions with high-risk for vitamin D deficiency were detected in 43% (206/474) of vitamin D requests (group 1). Conditions not associated with vitamin D deficiency were detected in 57% (268/474) requests (group 2). A total cost of 25(OH)D testing for the CHIF was 58,729.50 EUR (25,523.79 EUR in the group 1 and 33,205.71 EUR in the group 2). Conclusions: More than half of all 25(OH)D tests performed in the clinical laboratory represent avoidable cost for the public healthcare. Prevention of population screening by vitamin D testing is needed.
Article
Problem definition: We study the effects of emergency department (ED) physician workload on healthcare system utilization after the patient leaves the ED. Further, we explore the mediating effects of care intensity in the ED on post-ED care use. Academic/practical relevance: ED crowding has been a pressing concern in healthcare systems in the United States and other developed countries. As such, many researchers have studied its effects on outcomes within the ED. In contrast, we present novel results regarding the impacts of ED crowding on system performance outside the ED—specifically, on post-ED care utilization. Methodology: We utilize a data set assembled from more than four years of microdata from a large U.S. hospital and exhaustive billing data in an integrated health system. We use count models and instrumental variable analyses to answer the proposed research questions. Results: We find that there is an increasing concave relationship between ED physician workload and post-ED care use. When ED workload increases from its fifth percentile to the median, the number of post-discharge care events (i.e., medical services) for patients who are discharged home from the ED increases by 5%, and it is stable afterward. Further, we identify physician test-ordering behavior as a mechanism for this effect; when the physician is busier, she responds by ordering more tests for less severe patients. We document that this “extra” testing generates “extra” post-ED care utilization for these patients. Managerial implications: This paper contributes new insights on how physician and patient behaviors under ED crowding impact a previously unstudied system performance measure: post-ED care utilization. Our findings suggest that prior studies estimating the cost of ED crowding underestimate the true effect, as they do not consider the “extra” post-ED care utilization.
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Background: Both in medicine and in psychiatry, it's essential to find a general definition for medical and mental disorders. For this we have analyze the concepts behind these definitions. In this article, we intend to review the proximity between the concepts of mental and medical disorders regarding the presence of values, and to propose a way to deal with the different kinds of values that might be present. Methods: The method used in this paper was a conceptual review/analysis. Results: Regarding the concept of medical disorder, it has resorted to different sub-concepts such as dysfunction and harm (distress disability). The concept of dysfunction, apparently being less value-laden, has been prioritized in relation to the harm component although several authors have already proved that implicitly and explicitly this concept is value laden. In medical-surgical disorder it is very unlikely to find any diagnostic information that includes moral values. In this type of disorder, the values in question are universally non-moral: pain, disability, distress (or risk for these) and risk of death. On the other hand, in several mental disorders, moral values have often been included in their diagnostic criteria. Conclusion: It is concluded that values are present in the main concepts that have been used to define medical or mental disorder. What is essential is to understand what is descriptive and what is value and to try to avoid moral values in this context.
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A lot of money can be made from healthy people who believe they are sick. Pharmaceutical companies sponsor diseases and promote them to prescribers and consumers. Ray Moynihan, Iona Heath, and David Henry give examples of “disease mongering” and suggest how to prevent the growth of this practiceThere's a lot of money to be made from telling healthy people they're sick. Some forms of medicalising ordinary life may now be better described as disease mongering: widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments. 1 2 Pharmaceutical companies are actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers. The social construction of illness is being replaced by the corporate construction of disease.Whereas some aspects of medicalisation are the subject of ongoing debate, the mechanics of corporate backed disease mongering, and its impact on public consciousness, medical practice, human health, and national budgets, have attracted limited critical scrutiny.Within many disease categories informal alliances have emerged, comprising drug company staff, doctors, and consumer groups. Ostensibly engaged in raising public awareness about underdiagnosed and undertreated problems, these alliances tend to promote a view of their particular condition as widespread, serious, and treatable. Because these “disease awareness” campaigns are commonly linked to companies' marketing strategies, they operate to expand markets for new pharmaceutical products. Alternative approaches—emphasising the self limiting or relatively benign natural history of a problem, or the importance of personal coping strategies—are played down or ignored. As the late medical writer Lynn Payer observed, disease mongers “gnaw away at our self-confidence.”2Although some sponsored professionals or consumers may act independently and all concerned may have honourable motives, in many cases the formula is the same: groups and/or campaigns are orchestrated, funded, and …
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Attention deficit hyperactivity disorder (ADHD) is a common, probably highly genetically conditioned, neurobiological disorder. Heritability of ADHD symptoms is up to about 75%. However, the mechanism is still not fully understood. Attention is focused mainly on genes of the dopaminergic and serotonergic system as well as many other genes. The paper presents a summary of the most significant genetic associations with ADHD.
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The second half of the twentieth century witnessed the emergence of a new model of chronic disease-diagnosed on the basis of numerical deviations rather than symptoms and treated on a preventive basis before any overt signs of illness develop-that arose in concert with a set of safe, effective, and highly marketable prescription drugs. In Prescribing by Numbers, physician-historian Jeremy A. Greene examines the mechanisms by which drugs and chronic disease categories define one another within medical research, clinical practice, and pharmaceutical marketing, and he explores how this interaction has profoundly altered the experience, politics, ethics, and economy of health in late-twentieth-century America. Prescribing by Numbers highlights the complex historical role of pharmaceuticals in the transformation of disease categories. Greene narrates the expanding definition of the three principal cardiovascular risk factors-hypertension, diabetes, and high cholesterol-each intersecting with the career of a particular pharmaceutical agent. Drawing on documents from corporate archives and contemporary pharmaceutical marketing literature in concert with the clinical literature and the records of researchers, clinicians, and public health advocates, Greene produces a fascinating account of the expansion of the pharmaceutical treatment of chronic disease over the past fifty years. While acknowledging the influence of pharmaceutical marketing on physicians, Greene avoids demonizing drug companies. Rather, his provocative and comprehensive analysis sheds light on the increasing presence of the subjectively healthy but highly medicated individual in the American medical landscape, suggesting how historical analysis can help to address the problems inherent in the program of pharmaceutical prevention. © 2006 by The Johns Hopkins University Press All rights reserved.
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How do we replace the old panels of conflicted experts? Ray Moynihan investigates