The overdiagnosis community targets solutions

Documenting overdiagnosis is the easy part. The real challenge is how to manage it

Lisa M. Schwartz, Steven Woloshin, Iona Heath, Ray Moynihan, Helen Macdonald

Once upon a time, overdiagnosis and too much medicine were fringe ideas. That is no longer the case.  Thanks to the efforts of a small but growing international community of researchers, medical journal editors, policy makers, and consumers these ideas have moved into the mainstream. Three major medical journals—The BMJ (Too Much Medicine), JAMA Internal Medicine (Less is More) and The Lancet (Right Care)—have run series dedicated to establishing a rigorous evidence base, stimulating debate and promoting practice and policy changes to address overdiagnosis and overtreatment.

Similarly, the Choosing Wisely campaign, which seeks “to help providers and patients engage in conversations about the overuse of tests and procedures” has spread from the United States to over 20 countries, most recently to Canada and the United Kingdom. [1, 2] Some media outlets have also contributed, notably the Seattle Time‘s series “Suddenly Sick,” the Milwaukee Journal Sentinel‘s Risk/Reward series, and most recently, BBC Radio’s Inside Health programme and national television programmes from Danmarks Radio on overdiagnosis and informed choice. Consequently, the number of medical journal articles and news stories about overdiagnosis has increased exponentially over the past decade.

The Preventing Overdiagnosis conference—a collaboration of organisations including The BMJ, Oxford’s Center for Evidence-based Medicine, the Dartmouth Institute for Health Policy and Clinical Practice, Bond University, and Consumer Reports—provides a forum to advance the research agenda, stimulate policy change and promote communication between clinicians, researchers, policy makers and the public. The inaugural conference in 2013 focused on how to define and measure overdiagnosis and its consequences. Subsequent conferences have increasingly highlighted how to move forward. Last year, for example, Catherine Calderwood, Chief Medical Officer for Scotland since 2015, described overdiagnosis and overmedicalisation as her major public health challenge and her proposal of “Realistic Medicine” as the appropriate policy response.  This has been enthusiastically taken up across Scotland with initiatives at every level. And William Black, Professor of Radiology at Dartmouth, reported on how radiologists were taking the lead to rein in overdiagnosis by considering whether to raise the bar to act on pulmonary nodules which might conceivably be cancer. This is very unusual since professional organizations have historically lowered bars, defining more—rather than fewer—previously healthy people as sick. [3] Recently, the Fleischner Society Guidelines, those most commonly followed by radiologists, actually raised the bar. In response to evidence that too many people were being unnecessarily diagnosed with nodules that have a very low probability of being cancer, the new guidelines recommend no routine follow-up for solitary nodules less than 6 mm in low-risk patients (the previous threshold was less than 4mm) and have liberalized follow-up intervals for larger nodules to incorporate clinician and patient preferences. [4]

The theme of this year’s conference is moving “towards responsible global solutions.” The conference is hosted by the Quebec Medical Association, which has developed and is currently implementing a province-wide plan to tackle overdiagnosis, for example with a rolling series of meetings with clinicians about the problem. [5] A second theme is working towards better patient partnerships: for the first time, citizen/patient representatives sit on the scientific steering committee, a plenary will be devoted to the topic and a patient/citizen representative will provide commentary in each of the other plenaries.

Today The BMJ have published a series of articles about overdiagnosis to coincide with the conference.

In an analysis piece, Pathirana, Clarke, and Moynihan provide a broad overview of the possible causes of overdiagnosis and potential solutions. [6] The results of their explicit search highlight the limitations of the overdiagnosis literature on drivers and solutions: much of it was commentary and opinion (albeit based on growing empirical evidence the problem exists across a range of conditions), and only one systematic review was included in their analysis.  Key drivers identified included cultural beliefs like “more is better,” financial incentives to do more, and expanding disease definitions. Widely recommended solutions include evidence-informed awareness-raising and education strategies targeting the public and professionals, enhanced evaluation of diagnostic technology, and shifting incentives from quantity to quality.

In a new addition to The BMJ’s series on expanding disease definitions and overdiagnosis, Tessa Copp and colleagues make the case that expanded diagnostic criteria may be leading to the overdiagnosis of Polycystic Ovary Syndromeparticularly in mild forms and in younger women. [7] They argue that the diagnostic label can unnecessarily scare women about infertility and subsequent health problems and may not be needed to effectively treat distressing symptoms. The article contains a box of key facts that clinicians can share with women to explain the diagnosis and its uncertainties.

Two articles illustrate how testing can fuel overdiagnosis. Ricardo Quinonez and colleagues suggest that use of oximetry, a potentially life-saving technology for critically ill patients, is overused in stable infants and children with bronchiolitis, a self-limiting disease. They believe that the main effect of routine oximetry in bronchiolitis is not better care but overdiagnosis: a substantial increase in hospitalization without any evidence of improved outcomes. Hoffman and Welch, raise alarm bells about the proliferation of new, technologically advanced tests which are extremely attractive to investors but may be decidedly unattractive to anyone concerned about public health. [8] Each case study shows that the tests for cancers, Alzheimer’s disease, and the vital sign monitors may do more harm than good. While a small proportion of people may be helped, many more will be harmed by false alarms, overdiagnosis, and overtreatment. The authors offer advice on how clinicians can approach new tests thoughtfully: educate patients about harms as well as possible benefits, reserve tests for higher risk patients, and be aware of misleading feedback (i.e. overdiagnosed patients have a great prognosis not because testing helped but because they weren’t sick to begin with).

Finally, Stacy Carter uses different ethical frameworks to understand patients’ and clinicians’ moral and emotional responses to the tradeoffs of screening, and diagnostic and treatment thresholds, trying to bridge individual and population perspectives. [9] What does that mean for clinical practice and policy making? Carter seems to believe that tackling overdiagnosis will be best done at a system level and that it should on the whole be driven by utilitarian principles.

A growing body of evidence documents an unfortunate reality: the act of diagnosis inevitably introduces the possibility of overdiagnosis. Documenting overdiagnosis is the easy part. The real challenge is how to manage it.

Lisa M. Schwartz and Steven Woloshin, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.

Iona Heath, Royal College of General Practitioners.

Ray Moynihan, Centre for Research in Evidence-Based Practice, Bond University.

Helen Macdonald, Head of education, The BMJ.

Competing interests: Drs. Schwartz, Woloshin, Heath, Moynihan and MacDonald serve on the steering committee for Preventing Overdiagnosis. Drs. Woloshin and Schwartz serve as expert witnesses in testosterone legislation. The authors have no other conflicts to declare.

References:

  1. American Board of Internal Medicine. Choosing Wisely.  Accessed August 5, 2017.
  2. Bertelsmann Stiftung (Editor). Choosing Wisely: Learning from international experience. 2017.  Accessed August 5, 2017.
  3. Moynihan R, Cooke G, Doust J, et al. Expanding Disease Definitions in Guidelines and Expert Panel Ties to Industry: A Cross-sectional Study of Common Conditions in the United States. PLoS Med 2013 doi: https://doi.org/10.1371/journal.pmed.1001500
  4. MacMahon H, Naidich D, Goo J, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 2017;284:228-43.
  5. Québec Medical Association. Overdiagnosis: Findings and Action plan. Québec; 2014 http://www.preventingoverdiagnosis.net/2014presentations/surdiagnostic-plan-action-en (Abs57).pdf.
  6. Pathirana T, Clark J, Moynihan R. Overdiagnosis & related overuse: mapping drivers to potential solutions. BMJ 2017;358:j3879
  7. Copp T, Doust J, Mol B, et al. Are expanding disease definitions unnecessarily labelling women with Polycystic Ovary Syndrome? BMJ 2017;358:j3694
  8. Hoffman B, Welch H. New diagnostic-tests: more harm than goodBMJ 2017;358:j3314
  9. Carter S. The complicated ethics of overdiagnosis. BMJ 2017;358:j3872

 

  • Huw Llewelyn

    The problem is that EBM as currently promulgated does not include the tools to find the solutions to over-diagnosis. RCTs are not used currently to identify who benefits and to what extent. Sensitivity and specificity are used to assess non-numerical screening tests and to place cut-offs for numerical tests. They do not help to assess tests for use in differential diagnosis, diagnostic
    criteria and or offering treatments to patients to consider, which is why we have over-diagnosis and over-treatment.

    One example of how to assess tests in order to avoid over-diagnosis was described in an over-diagnosis conference some years ago by stratifying patients within an RCT [1]. However, there seems to have been little interest in solutions until now. If we wish to apply such solutions, we need doctors and other health professionals who are familiar with the thought processes of day to day patient care who are also mathematicians and statisticians. This approach is now being taught to students [2].

    It is not only the public, industry and health professionals who need a change of culture and education. There is a need for those who do research and promulgate EBM to expand their skills and horizons in order that they can help to provide solutions to current problems.

    References
    1. Llewelyn H. Reducing over -diagnosis and
    over-treatment by improving their criteria and stratifying them. Preventing
    Overdiagnosis Conference, Oxford, 2014, poster 34. http://www.preventingoverdiagnosis.net/2014presentations/Board%2034_Huw%20Llewelyn.pdf
    2. Llewelyn H, Ang AH, Lewis K, Abdullah A. The
    Oxford Handbook of Clinical Diagnosis, 3rd edition. Oxford University Press,
    Oxford, 2014, pp 615 – 664. http://oxfordmedicine.com/view/10.1093/med/9780199679867.001.0001/med-9780199679867-chapter-13

  • Huw Llewelyn

    The missing elephant in the room of over-diagnosis is failure
    to use evidence based criteria for diagnosis (see my recent rapid
    response in the BMJ: http://www.bmj.com/content/358/bmj.j3879/rr).
    Evidence-based diagnosis is currently based merely on the screening indices of sensitivity
    and specificity but in any case, these depend on having a ‘gold standard’ in
    the first place. Currently it seems to be assumed naively that gold standard tests
    are self evidently true, which is the root cause of over-diagnosis.

    Some of the basic principles of an evidence based solution to over-diagnosis were outlined in a poster by me at the Over-diagnosis Conference in Oxford in 2014: http://www.preventingoverdiagnosis.net/2014presentations/Board%2034_Huw%20Llewelyn.pdf.
    It is nice to know that there s a ‘growing interest’ in solutions now. I have
    been teaching the required basics of comprehensive evidence-base diagnosis for
    many years in the Oxford Handbook of Clinical Diagnosis: http://oxfordmedicine.com/view/10.1093/med/9780199679867.001.0001/med-9780199679867-chapter-13. What
    about a workshop on solutions to over-diagnosis based on such a broader view
    of evidence based diagnosis next year?