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...

Patient Story: Adventures in Choosing Wisely

Here's an awesome example of a patient who worked with her doctors to Choose Wisely.

Amy Berman has breast cancer that has metastasized to bone. She is a Registered Nurse (RN), a Senior Program Officer at the Hartford Foundation, and a vocal advocate for patient-centred care.

She decided with her doctors that she would benefit most from treatment with a single fraction of palliative radiotherapy instead of an extended course. The goal of this being some relief from the pain that stemmed from the new area of cancer on her ribs.

Her choice is in keeping with the evidence and recommendations of the Choosing Wisely items in Radiation Oncology. In the USA, the guidelines developed by The American Society for Radiation Oncology (ASTRO) suggest:

  • "Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases." 

 The Canadian Association of Radiation Oncology, in their version of recommendations, suggest:

  • "Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis."

Further, they explain: "Randomized trials have established that single-fraction radiation to a previously unirradiated, uncomplicated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity compared to multiple-fraction regimens, while optimizing patient and caregiver convenience. Although it results in a higher incidence of retreatment at a later date (20% vs. 8 % for multi-fraction regimens), the decreased patient burden usually outweighs any considerations of long-term effectiveness for those with a limited life expectancy."

Arranging this appropriate treatment was harder for Amy (and her doctor) than just making the choice. See her blog post to find out more, as there was more to the story! It appears that not everyone is on board with Choosing Wisely, yet  . . .

Source: http://www.jhartfound.org/blog/adventures-...

Myths and MSUs

Urinary tract infections (UTIs) are common in the elderly. They are also commonly overtreated. This can result in adverse reactions to medication including side effects like upset stomach or diarrhea, interactions with other drugs like coumadin (a blood thinner), or allergic reactions. There is also the potential loss of normal flora (good bacteria in our body) leading to overgrowth of C. difficile (bad gut bacteria) or Candida spp. (yeast) and development of antibiotic resistant organisms (AROs). Assuming someone has a UTI when they don't might also mean missing the real diagnosis.

This issue is unsurprisingly #1 on the Canadian Geriatric Society's Choosing Wisely hitlist: "Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present."

The Association for Elderly Medicine Education (AEME) has released a handful of excellent Mini-GEMs (Geriatrics E-learning Modules) on their youtube channel. This one, on "Myths and MSUs", where MSU = mid-stream urine test, was recently brought to my attention. It's aimed at physicians, but the take away for patients would be to ask "I feel fine and don't have any symptoms - do I really need an antibiotic for my bladder?"

I think it's a really clear walk-through of how to manage bladder infections, with a view to understand colonization (bacteria hanging out in the bladder that isn't causing harm) and interpreting the dip-stick test so as to avoid overtreatment. It's also a good reminder that, although common, a UTI is not always the cause of delirium, a temporary state of confusion secondary to underlying illness usually in the elderly.

Here's the video:

This MiniGEM explains how and when to diagnose UTI in older patients, and common pitfalls to avoid!
Source: https://www.youtube.com/watch?v=JPzz6fcmxo...