The Upshot reflects: Patients overestimate benefit and underestimate harm of tests & treatments

In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.

Their Conclusions and Relevance section explains the take-away it nicely:

The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.

This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.

For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer. 

94% of patients overestimated the benefits of bowel cancer screening.

Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:

Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.

 These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.


Does screening for disease save lives in asymptomatic adults? NO

I remember learning in medical school about what a screening test is and the factors necessary to make a 'good' screening test.

The disease in question should:
- constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality.
- have a readily available treatment with a potential for cure that increases with early detection.
The test for the disease must:
- be capable of detecting a high proportion of disease in its preclinical state
- be safe to administer
- be reasonable in cost
- lead to demonstrated improved health outcomes
- be widely available, as must the interventions that follow a positive result 

(American Medical Association Council on Scientific Affairs. Commercialized Medical Screening (Report A-03). no longer available online, but cited on Virtual Mentor)

We have obviously lost our way!!

In medical school I was excited about ensuring every patient got ALL THE SCREENING! I never thought I'd struggle to justify a screening test. 

These days, I would be hard-pressed today to confidently name you one "good" screening test. Maybe paps? Maybe colonoscopies? I follow my jurisdiction's guidelines. I discuss the risks and benefits of screening with patients because I'm not certain that what we are doing is definitely "good."

It's hard to summarize it any more clearly than this:

Among currently available screening tests for diseases where death is a common outcome, reductions in disease-specific mortality are uncommon and reductions in all-cause mortality are very rare or non-existent.

A paper in the International Journal of Epidemiology from June 2014 that just came to my attention recently draws this conclusion.

The authors looked at data from 48 Randomized Controlled Trials (RCTs) and 9 meta-analysis on the subject of screening tests (39 of them) for 19 potentially deadly diseases. The studies they included regarded things like mammography for breast cancer, echocardiography for heart disease, PSAs for prostate cancer, and so on.

Some limitations are acknowledged but I also wonder if there is another. For very worthwhile "common sense" things (if these things exist, and I'm not saying they do!) there is little published data. For example, the efficacy of the newborn screening exam or GBS screening in pregnancy don't seem to have been thoroughly studied but are considered to be "law, written in stone" in practice. For the more controversial screening tests, there are more trials published, and so that might weight this meta-analysis towards saying that screening tests on the whole are not useful. I actually think the conclusion the their analysis is appropriate, as the closer we look at other "written in stone" practices, the more we realize we were wrong!

This sentence in the discussion of the article I think sums up the complex nature of the results really well:

There are many potential underlying reasons for the overall poor performance of screening in reducing mortality: the screening test may lack sufficient sensitivity and specificity to capture the disease early in its process; there are no markedly effective treatment options for the disease; treatments are available but the risk-benefit ratio of the whole screening and treatment process is unfavourable; or competing causes of death do not allow us to see a net benefit. Often, these reasons may coexist. Whether screening saves lives can only be reliably proven with RCTs.

See for yourself! Read the full article.


Projects and Initiatives toward Appropriateness in Medicine: Health Quality Ontario

When I started this website, the ambition was to collect and curate information. So much fantastic research and advocacy has already been undertaken in the area of Appropriateness in medicine, but there was no "one-stop shop" for it.

This growing movement is known by many names, like RightCare, Quaternary Prevention, Overdiagnosis, Appropriateness, Less is More in Medicine, and so on. In Canada, we seem to favour the "Appropriateness in Health Care" phrase.

The field now has so much momentum that it can be hard to keep track of everything. It's a great problem to have when you are passionate about this way of thinking, but as I'm only one person I can miss lots of great things! A friend pointed out a glaring (and wonderful, Canadian) omission:

It is the Health Quality Ontario Appropriateness Initiative, which created a systematic framework for identifying, prioritizing and assessing interventions that are potentially being used inappropriately; they offer evidence reviews and recommendations. Some topics include Measuring HbA1cs in Diabetes and Testing Vitamin B12 Levels in Neuropathy, Alopecia, Dizziness, and Fatigue.

There are many other initiatives, beyond this one and the fairly well-know Choosing Wisely campaign. See the list of PROJECTS for more.