Overdiagnosis across medical disciplines: a scoping review | BMJ Open

Curious about which areas of medicine have more problems with overdiagnosis than others? Wondering in which fields the problem has been studied extensively? A group from the Netherlands has looked into this extensively in their paper: Overdiagnosis across medical disciplines: a scoping review for BMJ Open.

One of the biggest challenges in exploring this area is that the problem of 'too much medicine' goes by many different terms, these vary from place to place, and even where the same term is used there is disagreement about definitions. 

Jenniskens, a PhD student at Utrecht University, et al looked at almost 5000 studies and included 1581 for review. Unsurprisingly, the majority of papers pertained to the field of oncology, perhaps because wide-spread screening programs and attempts for early diagnosis are much more common for cancer than for chronic disease and other conditions. Though they did not publish the information, they also took a moment to determine from where in the world the papers were being written.

For years, I have been fascinated with the geographically diverse response to the problem of overdiagnosis and the idea that overdiagnosis can happen in resource-rich and -poor countries alike. I worked with Alan Cassels to facilitate a group discussion at the Preventing Overdiagnosis conference in Barcelona in 2016. We identified movements that attempt to combat overuse of tests, treatments, and procedures around the world (presentation slides are available here) and discussed what factors in each region might be playing a role.

Seeing that presentation and recognizing my interest, Mr Jenniskens has since kindly provided me with a breakdown of the country of origin of the authors for the papers analyzed in his group's review. While most of the papers were tied to the United States, first authors from 65 different countries were among the 1581 papers.

 Grey - no authors; Light Green - few authors; Orange - many authors.

Grey - no authors; Light Green - few authors; Orange - many authors.

Please click through to interactive map to view the % proportion of authors of the 1581 assessed papers, originating from each country. From Albania to Zimbabwe, it is clear that overdiagnosis is a global concern, and is being researched everywhere.

Read more about the papers considered in the scoping review.

Source: http://bmjopen.bmj.com/content/7/12/e01844...

VIDEO: The Truth about Mammograms - Adam Ruins Everything

Here's a great, brief explainer about the problems with mammography (and most cancer screening)  - 2:43

A slightly longer/better version is here on TruTV's website: The Truth About Mammograms - Full Episode (4:30)

Source: http://www.trutv.com/shows/adam-ruins-ever...

VIDEO: #ChoosingWisely in Cypress Health Region

Since 2015, The Saskatchewan Health Quality Council has been moving forward the very important agenda of Appropriateness of Care.

 

In partnership with the Saskatchewan Medical Association, they have now launched Choosing Wisely Saskatchewan and are working engaging patients, clinicians, and learners to implement a province-wide strategy to tackle overuse. To start, they are focussing on pre-operative testing and imaging of lower back pain, and some of the health regions are taking on their own projects.

The Cypress Health Region has demonstrated their commitment to Choose Wisely:

Here's hoping many people will see their example and make the same pledge to choose wisely - because more is not always better in healthcare.

Source: https://www.youtube.com/watch?v=gkqKRYpKbQ...

Mammogram Theater: A Visual Aid For Medical Decision-Making

With a title like "mammogram theatre" you would wonder if this post is meant to poke fun at the elaborate song and dance of mammography; we have spent years promising women that "early detection is key," only to realize that screening mammography cannot do what we originally hoped it could (but many still pretend it can).

Of course women want their breasts and lives saved. But the information on the benefits of mammography has been largely overstated in part due to cognitive biases (like lead-time bias, base-rate fallacy, etc), and the risks are too often left out of the conversation.

Every test has risk and benefits, but it can be challenging to decide if a test or treatment is right for you or your patient when there is too much information, experts disagree when they review the same studies, and the media has a constant see-saw back and forth of "yes" and "no" headlines that seem only to confuse. It can feel a bit like ping-pong, following the discussion back and forth. It's not really fair to ask patients to make sense of all this.

So yes, the promise of benefit of mammography may have been a bit of dramatization, but the theatre I speak of is a literal one. 

Dr. Andrew Lazris is an American internist who partnered with environmental scientist Erik Rifkin to popularize a simple, easy way of showing how many are helped and harmed by common tests and procedures.

Lazris and Rifkin have developed a tool to give people a realistic way of evaluating 'hope and worry;'

Their "benefit-risk characterization theater" images vividly show the odds, based on solid research. (read more on NPR)

This is a tool to help doctors and patients have informed discussions about the risks and benefits of breast cancer screening with mammography, to engage in shared-decision making on the topic. Take a look:

This tool has been added to the "hands-on tools" section of this website, where you can find other tools like it.

Source: http://www.npr.org/sections/health-shots/2...

Difficult patients. Sigh! (Impact of patient requests on provider-perceived visit difficulty in primary care)

 "No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

"No ma'am, your thumb isn't broken. I suspect the pain is as a result of pressing your call bell over 43 times in the last hour."

Sometimes physicians talk about the "difficult" patient with exasperation in their voice.  Nurses know these cases even better.

Most patients and families can tell your about a doctor or nurse who was terse, arrogant, disinterested, or even callous.

These encounters can be "soul-sucking," "difficult," and "draining." The individuals are labeled as "entitled," "unrealistic," "demanding," or ... worse.

That's not ideal terminology although the truth is that some patient encounters are harder than others, and we can't always figure out why. If we have a frustrating appointment, we equate the difficulty with the person, not the situation. As physicians, we often blame the patient!

"It's a personality disorder." "She's a rich, demanding snob." "He refuses to accept this."

On the surface are our attitudes, biases, and skill sets. Just like "difficult" doctors, "difficult" patients are, in our eyes, not open-minded, have not mastered skills of effective communication or listening, don't want to be told they are wrong, demand ridiculous things, or dig their heels in despite evidence that contradicts them.

Sometimes stubbornness is advocacy and it is necessary. Sometimes asking lots of questions is essential to developing an understanding from which a partnership can follow.

There is usually more to the story than just a clash of the personality of the clinician and the patient, and the health care provider should be sensitive to this; empathy means acknowledging that other people have "stuff" going on in their life. Fear, anger, embarrassment, uncertainty, and anxiety are among the many emotions that can make a clinical exchange sour.

With time and worldliness, and maybe some training, we grow and learn to help sort through that. Interestingly, the kind of encounters that health care providers find difficult are generally around people asking for tests.

According to Fenton et. al's paper, Impact of Patient Requests on Provider-Perceived Visit Difficulty in Primary Care, in the Journal of General Internal Medicine:

[Primary Care Provider] (PCP)-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of “choosing wisely,” PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider–patient relationship and PCP career satisfaction.

They looked at 824 clinical encounters. Even adjusting for medical and psychiatric conditions, it was asking for tests that made clinicians rate the encounter as more difficult.

Fortunately, there are tools to help with this. A (not well curated) collection of Shared Decision Making tools is available on this site. Another time, I'll write about the evidence of efficacy (or lack thereof?) behind these aids.

The Choosing Wisely campaign is a prominent effort to facilitate these conversations about unnecesary tests. The Canadian and American sites both have many educational resources to help us with discussing diagnostics and therapeutics, and the AAFP has a great article on difficult patient encounters

It's not rocket science. We must remember that patients are human beings. Hopefully they will extend us, as providers, the same consideration.

 At least he used the sensitive kind of tooth paste?

At least he used the sensitive kind of tooth paste?

Finally: yes, some people, whether doctors, patients, nurses, or family members, are just plain jerks.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2537383...

VIDEO: Do More Screening Tests Lead to Better Health? @docmikeevans

Many of you will be familiar with the hilarious and helpful work of Dr Mike Evans and his team. Their white board videos are a great blend of up-to-date evidence, patient perspective, and useful advice.

In Do More Screening Tests Lead to Better Health? you'll find more than just the answer to that question ("No.").

With a focus on healthy, well-feeling, average risk individuals, the video emphasizes that the harms of doing a test (and the sequelae of that test) may be greater than the benefit. This is a tough bit of information to accept particularly if you've already had lots of 'preventative tests' done and have felt reassured by them. However, it's really time to re-evalute their usefulness.

It's not that we should do nothing to prevent disease; instead of wasting a person's time and resources on unnecessary tests, the time can be better spent devoted to support around lifestyle choices that we know will lead to better health. Take a look:

Source: https://www.youtube.com/watch?v=8c7qTsVVxX...

How Rad is this? Academic Radiology dedicated "Overdiagnosis Issue" Aug 2015

The Preventing Overdiagnosis conference in Bethesda, MD this year was amazing for many reasons.

One of my favourite parts? Meeting all the people who are doing excellent work in the area of preventing harm to patients from unnecessary tests and treatments! I've been lucky to "know" quite a few motivated people on Twitter, but putting faces to names to twitter handles was really something.

Imaging my delight to meet @RogueRad, aka Dr Saurabh Jha, the developer of Value of Imaging and Assistant Professor of Radiology at the Hospital of the University of Pennsylvania, with a background (and Master's) in Health Policy Research. He is really interested in uncertainty as a driver of diagnostic imaging utilization and how we decide which tests have value.

It should not be surprising then that he handed me a copy of Academic Radiology; why? The August journal, with Jha's editorial hand, was dedicated entirely to Overdiagnosis! 

You can view the contents here. It is an impressive edition, with a Guest Editorial from H. Gilbert Welch and articles ranging from breast cancer screening to PET scanning in dementia to the role of Precision Medicine in confronting overdiagnosis. While I'm less optimistic about that last point, the August edition of Academic Radiology on the whole strikes a nice combination of hope and caution, balancing under- and over- diagnosis, even explicitly in the case of and article about this in the context of Mild Traumatic Brain Injury (MTBI).

Hopefully in the coming year we'll see more medical journals dedicating themselves to this issue with the help of keen leadership like that of Dr Jha.

Source: http://www.academicradiology.org/issue/S10...

​Choosing diagnostic tests wisely: Doing the little things well

* RESEARCH FIRST LOOK *

There was such a wonderful response to the Choosing Surgery Wisely paper from Dr Roland Grad and medical students Nicholas Meti and Mathieu Rousseau, that they have submitted another!

 Dr Grad's poster at PODC2015

Dr Grad's poster at PODC2015

You may remember Dr Grad, a family physician and researcher at McGill University, from his poster on harnessing InfoPOEMS to find potential topics for the Choosing Wisely Campaign, which he also presented at the Preventing Overdiagnosis conference this year (PODC2015). [click to view the more recent poster in PDF format]

Again, Rousseau and Meti worked with Dr Grad to extend this work and look at InfoPOEMs that dealt with three topics in diagnostic testing: stable TSH measurements, screening mammography, and mid-stream urine collection. Guided by clinical questions pertaining to these topics and the best available evidence, they make a clear case that we need to choose very wisely when considering 'routine' testing. There are some apt qualitative insights provided by physicians reflecting on the practice-changing POEMs (Patient-Oriented Evidence that Matters) included in this research, which will undoubtedly help it to resonate with readers.

Please feel free to leave questions or comments below or contact the authors directly. If you would like to submit a guest-post for consideration, email lessismoremedicine@gmail.com.


Choosing diagnostic tests wisely: Doing the little things well

Rousseau, M., Meti, N., Grad, R. Faculty of Medicine, McGill University, Montreal, Canada.
 

Introduction
 

As clinicians, do we challenge the appropriateness of our diagnostic test ordering? To achieve shared decision-making in health care, it is up to clinicians to communicate both the harms (as well as the benefits) of diagnostic testing. Within the concept of shared-decision making, there are three core practices: 1) Identifying that a decision must be made; 2) Communicating the potential benefits and harms of options to patients; and 3) Incorporating what is important to patients within the decision. The latter may require us to consider other questions: What would be the impact of this test on the patient’s quality of life? What about the interval between follow-up tests? What is the impact on the economy when diagnostic tests and follow-ups are considered at scale? When clinicians think about ordering a test (or not), we suspect their decision is based on “routines” and “experience”. The point of this post is not to argue against the “art of medicine”, but to raise awareness of new research that can inform decisions about diagnostic testing.

In this post, we highlight the findings of three recent diagnostic test studies. Study findings were disseminated to Canadian physicians as ‘POEMs’. For those unfamiliar with this acronym, POEMs are tailored synopses of primary research or systematic reviews, selected in a process that involves searching over 100 journals. [1] Since 2005, the Canadian Medical Association (CMA) delivers one POEM to their members by email on weekdays. As described in a prior guest post (Choosing Surgery Wisely), we identified the following POEMs by analyzing the ratings of all daily POEMs (n=255) collected from physician members of the CMA in 2014.
 

CLINICAL QUESTION: “How much do seemingly stable thyroid tests vary over time? / POEM Title: Stable TSH can be rechecked in 2 years”

In a cohort study, the authors asked how frequently do patients with treated hypothyroidism need to have their TSH measured. [2] From a sample size of over 700 persons treated with levothyroxine, they were able to identify a subgroup that would benefit from less frequent TSH monitoring based on their dose of levothyroxine. They report that patients receiving less than 125 micrograms per day could have their TSH rechecked in two years instead of annually. Importantly, this study highlights that once TSH has normalized, the frequency of subsequent monitoring can be stratified based on dosing.

Monitoring frequency is a relevant issue in the clinic setting. In the absence of evidence, many clinicians assume default rates for all manner of diagnostic test and treatment plans. We read the free-text comments submitted by CMA physicians about this POEM. Some of these physicians expressed surprise at the association between dose and frequency of monitoring. Others reported the following: had they known about this approach, they would have spread out the visits for their healthier patients. This would save time and provide costs savings for the healthcare system. Although not addressed by this study, one physician even raised the question of whether we need to be checking TSH levels at all in an asymptomatic patient.

 

CLINICAL QUESTION: “What are the trade-offs of benefits and harms for women considering a mammogram to screen for breast cancer? / POEM Title: Numbers to help women understand the benefits/ harms of screening mammography”

Welch et al. believe primary care physicians should have more balanced discussions with their patients about the benefits and harms of screening mammography. [3] Their premise is that the majority of discussions focus on the possibility of avoiding death from breast cancer, and do not include a discussion of false alarms nor overdiagnosis. The authors used currently available data from trials of screening mammography to give a range of estimates for harms and benefits with the hope that this information would help decisions about screening. Their results are summarized in this table. Note that the numbers are per-one-thousand women, screened yearly for 10 years:

Figure 1: Estimates of harms and benefits of screening mammography

We received mixed feedback from physicians who read this POEM. Some physicians were grateful to have empiric data to help them in their discussions with patients. One wrote it is “helpful to have the actual numbers presented in such a way that I can share info with the patient when discussing mammograms and screening - always easier when there are numbers that we can look at”, and these numbers “make discussion around breast cancer more objective”. However, others wrote that even though “it is much easier to communicate this information to a patient by simply selecting the age group she falls into, and presenting the numbers for that group [...], I have not yet had a patient who didn't just simply choose the mammogram”. It seems that numbers do not tell the entire story… “because this is an emotional issue, most women we counsel opt for the regular screening”.

The importance of this topic to primary care is high, because as one CMA member wrote “the harms of false positives are seen first-hand in primary care”.
 

CLINICAL QUESTION: “How accurately does a midstream urine culture predict the results of a catheterized urine culture? POEM Title: Interpretation of midstream urine cultures in healthy young women with suspected UTI”

What about the practice of empirically treating suspected urinary tract infection in otherwise healthy women without relying on culture? In a diagnostic test evaluation study, midstream urine cultures with any evidence of E. coli or K. pneumoniae strongly suggested a true infection, while the presence of enterococci or group B streptococci had little predictive value. [4]

Feedback from physicians who read this POEM showed appreciation for the findings and included comments such as this one: “As a walk-in clinic doctor, urinary symptoms are a very common reason for visits. I routinely treat women on spec for these UTI's and don't send their urine for culture unless it is a complicated UTI, the patient has significant comorbidities, or the patient has recently been on antibiotics.”

The practice of empirically treating suspected urinary tract infection in otherwise healthy women without relying on culture was recommended in a recent review by Grigoryan et al. [5] Her group reviewed the optimal approach for treating acute cystitis in young healthy women and analyzed studies totalling 259 397 patients. This showed that “immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone”.

This choosing-wisely-approach to a common infection was perfectly summarized in this comment submitted by another physician: “great info [in this POEM]. Sometimes we just do too much testing”.
 

Conclusion
 

As we reflect on all this, we see that even if one test “can’t hurt”, at scale the impact can be large for publicly funded health care systems. This point has been made by others. For example, Kale et al showed how “routine” diagnostics tests cost large sums of money. [6] Primary health care faces a big challenge in reconsidering how diagnostic testing is used, to ensure better value for all.
 

References
 

1. Grad RM, Pluye P, Tang DL, Shulha M, Slawson DC, Shaughnessy AF. 'POEMs’ suggest potential clinical topics for the Choosing Wisely Campaign. Journal of the American Board of Family Medicine 2015;28:184-189. http://www.jabfm.org/content/28/2/184

2. Pecina J, Garrison GM, Bernard ME. Levothyroxine dosage is associated with stability of thyroid-stimulating hormone values. Am J Med 2014;127(3):240-245 http://www.amjmed.com/article/S0002-9343(13)01021-8/abstract

3. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med 2014; Dec 30 http://archinte.jamanetwork.com/article.aspx?articleid=1792915

4. Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream urine culture and acute cystitis in premenopausal women. N Engl J Med 2013;369(20):1883-1891 http://www.nejm.org/doi/full/10.1056/NEJMoa1302186

5. Grigoryan L, Trautner BW, Gupta K. Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting. JAMA. 2014;312(16):1677-1684. http://jama.jamanetwork.com/article.aspx?articleid=1917443

6. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. Arch Intern Med 2011;171(20):1856-1858

Incidentalomas: What they are and why we should be concerned | Jill Wruble | TEDxPenn - YouTube

At the Preventing Overdiagnosis conference, I met a wide variety of people all dedicated to the same cause: the pursuit of better care for patients by way of helping them to avoid unnecessary and harmful tests and treatments.

By chance I met Dr Jill Wruble, a radiologist at Veterans Medical Center in West Haven, Connecticut and Clinical Assistant Professor with Yale and the University of Connecticut.

We talked about incidentalomas and what could be done to help improve our handling of them. When Jill told me about her TedX talk, I knew it would be worth checking out. She models appropriate care in her practice, teaches colleagues and residents, and has been making efforts to inspire others to make sure they are using diagnostic imaging meaningfully and judiciously. And she's a pretty amazing woman - did you see that bio!?

 

Not sure what an incidentaloma is? Or what to do if you find one (or are told you have one)? See her 15 minute talk on the subject:

 

Source: https://www.youtube.com/watch?v=vrjx8ikME7...

JOKE: Your Duck is Dead #overdiagnosis

An friend of mine (LL) sent this story to me and I think you'll find it illumniating. No, it's not about quacks!

Your Duck is Dead

A woman brought a very limp duck into a veterinary surgeon. As she laid her pet on the table, the vet pulled out his stethoscope and listened to the bird's chest.

After a moment or two, the vet shook his head and sadly said, "I'm sorry, your duck, Cuddles, has passed away."

The distressed woman wailed, "Are you sure?" "Yes, I am sure. Your duck is dead," replied the vet.

"How can you be so sure?" she protested. "I mean you haven't done any testing on him or anything. He might just be in a coma or something."

The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black Labrador Retriever. As the duck's owner looked on in amazement, the dog stood on his hind legs, put his front paws on the examination table and sniffed the duck from top to bottom. He then looked up at the vet with sad eyes and shook his head.

The vet patted the dog on the head and took it out of the room. A few minutes later he returned with a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back on its haunches, shook its head, meowed softly and strolled out of the room.

The vet looked at the woman and said, "I'm sorry, but as I said, this is most definitely, 100% certifiably, a dead duck."

The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman. The duck's owner, still in shock, took the bill. "$150!" she cried, "$150 just to tell me my duck is dead!"

The vet shrugged, "I'm sorry. If you had just taken my word for it, the bill would have been $20, but with the Lab Report and the Cat Scan, it's now $150."