THESIS: Preventing Overdiagnosis, the Quaternary Prevention

Maria Llargués Pou, a soon-to-be Family Physician in Barcelona, recently shared with me her Bachelor's Thesis. 

Her work - "Primum non nocere" Preventing Overdiagnosis, the Quaternary Prevention provides a concise introduction to the efforts around the world to prevent overuse of tests, treatments, and disease-labels, as well as the reasons we must address this growing issue.

 

Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy 

Llargués Pou has beautifully laid out an evolution of ideas, from Ivan Illich's idea of Iatrogenesis, to Jamoulle's attempts to thwart iatrogenic harm with a public health model of Quaternary Prevention, and now, contemporary efforts to tackle overdiagnosis, like the Choosing Wisely Campaign and Preventing Overdiagnosis conference. Her paper serves as a great "backgrounder" for those who wish to learn more about the broad themes and history of this movement.


You can view the full text HERE.

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: A troubling pharmaceutical cocktail | Dee Mangin #WalrusTalks

Polypharmacy-smashing superstar Dee Mangin delivered a compelling talk for The Walrus about the problem of too much medicine.

In just over 8 minutes, she beautifully articulates the issue and a vision of how we can address it.

Source: https://www.youtube.com/watch?v=QQkV7yHuQ-...

Wake up and smell the #overdiagnosis

Alan Cassels is not a shy kind of guy. He tells it like it is and is not one to stay quiet even if what he says may be unpopular. 

And usually it is pretty unpopular. 

However, it is necessary. From calling out the BC government's inaction on Choosing Wisely to fighting the overmedication of Canadian seniors and digging into the Sex, drugs, and rockin' beat of tramadol and tramacet's marketing machine, he is not afraid to talk about the elephants in the room, when it seems no one else is willing.

 

Cassels is a policy analyst, author, and champion debunker when it comes to pharmaceutical policy and the medicalization of Canadians.

In his most recent article for Focus Magazine, Cassels highlighted the Preventing Overdiagnosis conference, the harms of prostate cancer screening, and my perspective on the issues. 

I've had the chance to work with Cassels on a few small projects but to be called a 'resistor' by him feels like quite a pretty high honour! Check it out in Focus.

A New Kind of Rounds: Type 2 Diabetes in the Elderly CME

Thanks to my local Division of Family Practice and the Practice Support Program (PSP), we were able to put together "A New Kind of Rounds" event all about helping patients find the right amount of medicine. 

Our first event, focussed on Type 2 Diabetes in the Elderly, and specifically the harms of treating this too aggressively. Inspired by the Lown Institute's RightCare Rounds and the DoNoHarm Project, we started with patient cases in which the patient's perspective highlighted the burden of treatment and the potential harms of too much medicine.

After small-group case learning, I presented a didactic session reviewing the unique factors that change our approach to management in the elderly, the best available evidence on diagnosis and treatment targets, the current guidelines, and some resources that clinicians and patients can refer to in order to make shared decisions about the "right amount" of care.

The event was well-attended and it was heartwarming to see the level of engagement on this topic from clinicians in our community; we are reviewing the evaluations to consider some changes to the format. Participants also generated an amazing of possible topics for future events, from hypertension to cancer-screening, and anti-psychotic use in the elderly to the annual physical. 

The slides are available here.

Your feedback is most welcome. You can comment below or e-mail. 

My other lectures can be viewed here.

Source: http://prezi.com/ln78vzbqpu4-/?utm_campaig...

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...

It's #PODC2015 time: Preventing Overdiagnosis 2015 is here

After an incredible General Council (the annual meeting of the Canadian Medical Association), it is now time for me to zip off to Bethesda, MD for Preventing Overdiagnosis.

Although I attended last year in Oxford, this will be my first time speaking at the conference; I have the fortune of working with Dr James Rickert (who challenges conflict of interest in orthopedics and puts the patient first) in order to present a workshop around some of the criticisms (and related solutions) for the Choosing Wisely campaign (at 11:30, Weds Sept 2nd).

I would say that I am Choosing Wisely's biggest fan, and biggest critic. I am looking forward to the opportunity to hear more thought from my peers about the campaign and what the next steps might entail. There is so much hope and opportunity with this initiative and it's a great time to strengthen it and to reach higher!

This conference will also be a great opportunity to reflect on the past couple of years and the progress that so many people have made, and to meet up with colleagues to hear about their planned work going forward. There will be quite a few curious and critical-thinking Canadians in attendance, including (I hear):

-   Dr. Laurent Marcoux (former head of the Quebec Medical Association, one of the key developers of their Action Plan for Overdiagnosis

-    Dr. Roland Grad (researcher in family practice currently looking at harnessing infoPOEMs to identify low-value tests and treatments)

-    Dr. Rita McCracken (finishing her PhD, an expert on polypharmacy/deprescribing in the elderly)

-    Dr. Tracy Monk (humble yet highly effective champion and practicer of patient centered, evidence-based, and relationship-based care)

-    Dr Alan Cassels (co-author of Selling Sickness and highly sensible drug policy researcher)

-    Joanna Trimble (family member and advocate for confronting polypharmacy and sedative overuse in the elderly, at Is Your Mom On Drugs?)

-    Dr. Danielle Martin (head of Canadian Doctors for Medicare and outspoken advocate for doing more with less)

-    Dr Sacha Bhatia (chair of evaluation and can-do pioneer for Choosing Wisely Canada)

-    Dr Jennifer Young (leader of the Don’t Just Do Something, Stand There workshop with the Ontario College of Family Practitioners)

Go Canada!

And that is just the tip of the iceberg. The entire conference will be comprised of like-minded peers from around the world. I can't wait to get started tomorrow; see you there!!!

 

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."

Giving Doctors Grades - The New York Times

Kelly Blair's illustration of health care grades

Kelly Blair's illustration of health care grades

I write a lot about well-intentioned tests and treatments for patients leading to (unintended but very real) negative consequences.

For example: high cholesterol is linked to heart attacks and heart attacks kill. We have a kind of drug that lowers cholesterol (statins). Give the drug, lower the cholesterol, lower the number of heart attacks. So, we put everyone on statin drugs, yay! 

Except, no. Physiology is not logic; lowering cholesterol with statins may NOT lower the number of heart attacks or it may not do so in most people. And statins don't actually save lives in people who don't already have heart disease. But many people (~1/10) given this statin drug will experience unpleasant side effects, like daily muscle cramps. (theNNT.com)

Good intentions, bad results. Surrogate markers are not meaningful.

 

That understood, it should not be surprising to see this thinking error applies not only to physiology but also to the health care system, a system (like the human body) that does not follow the simple rules of logic.

Well-intentioned quality or performence measures can lead to unintended and very negative consequences. This NY Times article, Giving Doctors Grades, illustrates this problem perfectly.

While trying to ensure high quality care, some metrics are set. These metrics are meant to be measured repeatedly to ensure that whatever changes are made result in better and better patient outcomes, lower costs, etc. Unfortunately, the choice of metrics can drive physicians to behave badly, in order to score higher on their report cards. To get the best outcomes, surgeons stop helping the sickest people and surgerize the healthy instead.

Bad things happen to patients that did not need things done to them.

My own provincial medical association, Doctors of BC, and many other organizations in Canada have discussed measuring physician performance. We as physicians want to be accountable to our patients, and the public wants this too. Our common goal: that dangerous, unsafe practices be weeded out and high quality care be supported and applauded.

We must proceed very very carefully when we put measurements in place lest we incentivize the wrong thing and do more harm than good.

Read more in the NY Times.

Source: http://www.nytimes.com/2015/07/22/opinion/...

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...