Overuse of medical care : a well-recognized problem

2017 Update on Medical Overuse : A Systematic Review

2017 Study Abstract

Objective
To identify and highlight original research articles published in 2016 that are most relevant to understanding medical overuse or strategies to reduce it.

Evidence Review
A structured review of English-language articles on PubMed published in 2016 coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adults. These articles were appraised for their importance to medicine.

Findings
This study considered 2252 articles, 1224 of which addressed medical overuse. Of these, 122 were deemed most relevant based on originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by author consensus. Select findings from the studies include the lack of benefit of transesophageal echocardiography in the workup of cryptogenic stroke, increasing use of computed tomography in the emergency department from 2.2% to 9.4% from 2001 to 2010, and carotid ultrasonography and revascularization being performed for uncertain or inappropriate indications with 95% frequency. Likewise, services for which harms are likely to outweigh benefits include treatment for early-stage prostate cancer, which provides no mortality benefit but increases absolute risk of erectile dysfunction by 10% to 30%, oxygen for patients with moderate chronic obstructive pulmonary disease, surgery for meniscal tear with mechanical symptoms, and nutritional interventions for inpatients with malnutrition. This review highlights 2 methods for reducing overuse: clinician audit and feedback with peer comparison for antibiotic use (reduction in inappropriate antibiotic use from 20% to 4%) and a practical and sensible shared decision-making tool for low-risk chest pain (reduction in emergency department workup from 52% to 37%).

Conclusions and Relevance
The body of empirical work continues to expand related to medical services that are provided for inappropriate or uncertain indications. Engaging patients in conversations aimed at shared decision making and giving practitioners feedback about their performance relative to peers appear to be useful in reducing overuse.

The Real Reason Hospitals Are So Expensive

Adam Ruins The Hospital – Season 2 | Ep 203, 2017

American healthcare might not be the best in the world, but it is the most expensive. Adam Conover explains that inflated hospital costs have created a system that’s unaffordable and unfair.

The Little Known Truth About Mammograms

Adam Ruins The Hospital – Season 2 | Ep 203, 2017

Mammograms might be able to detect cancer but they can’t tell the difference between different types. Turns out, mammograms can harm and save much fewer lives than you think.

Diagnostic tests : how to minimise harm

We must develop new diagnostic tests to tackle real health problems, not to generate them

New diagnostic tests: more harm than good, BMJ 2017;358:j3314,
06 January 2016.

Defenders against overdiagnosis, BMJ 2017;358:j3487, 20 July 2017.

Although new diagnostics may advance the time of diagnoses in selected patients, they will increase the frequency of false alarms, overdiagnosis, and overtreatment in others.

Bjorn Hofmann, professor of medical ethics at Norwegian University of Science and Technology, explains how to minimise harm. Press Play > to listen to the recording.

Key messages

  • Innovative technologies and ample venture capital are combining to produce new disease biomarkers and mobile monitoring devices
  • These new diagnostics are technologically advanced but do not automatically provide improvements in clinical care and population health
  • They have the potential to help some but also to increase the frequency of false alarms, overdiagnosis, and overtreatment in others
  • Excessive testing and false alarms may increase healthcare workload and shift clinicians’ focus towards the healthy
  • Misleading feedback at both the population and individual levels tends to favour further market growth
  • Clinicians must provide a strong counterbalance: educating patients, respecting baseline risk, thinking downstream, and expecting misleading feedback

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JAMA 2017 Guidance for Modifying the Definition of Diseases

Loose disease definitions cause millions misdiagnoses and excess testing/treatment. Checklist stops disease mongering

A landmark paper addressing overdiagnosis, published yesterday in the journal JAMA Internal Medicine, outlines the first serious attempt to set some global rules for those experts who move diagnostic goalposts that label more people as sick.

Abstract

Importance
No guidelines exist currently for guideline panels and others considering changes to disease definitions. Panels frequently widen disease definitions, increasing the proportion of the population labeled as unwell and potentially causing harm to patients. We set out to develop a checklist of issues, with guidance, for panels to consider prior to modifying a disease definition.

Observations

“Medical science is making so much great progress soon none of us will be well”
Allen Frances

We assembled a multidisciplinary, multicontinent working group of 13 members, including members from the Guidelines International Network, Grading of Recommendations Assessment, Development and Evaluation working group, and the World Health Organisation. We used a 5-step process to develop the checklist:

  1. a literature review of issues,
  2. a draft outline document,
  3. a Delphi process of feedback on the list of issues,
  4. a 1-day face-to-face meeting,
  5. and further refinement of the checklist.

The literature review identified 12 potential issues. From these, the group developed an 8-item checklist that consisted of definition changes, number of people affected, trigger, prognostic ability, disease definition precision and accuracy, potential benefits, potential harms, and the balance between potential harms and benefits. The checklist is accompanied by an explanation of each item and the types of evidence to assess each one. We used a panel’s recent consideration of a proposed change in the definition of gestational diabetes mellitus (GDM) to illustrate use of the checklist.

Conclusions and Relevance
We propose that the checklist be piloted and validated by groups developing new guidelines. We anticipate that the use of the checklist will be a first step to guidance and better documentation of definition changes prior to introducing modified disease definitions.

Sources and Media Releases
  • Changes in Disease Definition and Prevalence of a ConditionWiser Healthcare, 04:59 – 16 mai 2017.

    How does a new disease definition impact the prevalence of a condition ?
  • Checklist of Items to Consider When Modifying a Disease DefinitionWiser Healthcare, 03:31 – 16 mai 2017.

    Preventing #overdiagnosis: a checklist to guide modification of #disease definitions
  • Guidance for Modifying the Definition of Diseases, A Checklist, JAMA Internal Medicine Special Communication, doi:10.1001/jamainternmed.2017.1302, May 15, 2017.
  • How to rein in the widening disease definitions that label more healthy people as sick, the conversation, May 15, 2017.

The New War on Cancer

50-Year War on Cancer: Can We Win?

The signing of the National Cancer Act by President Richard M. Nixon on December 23, 1971, was considered a declaration of war on cancer.

In a multi-part series, the National Post explores why we need a new war on cancer.

Cancer nation

Where you live could affect your odds of getting cancer or dying from it.

Interactive map: Cancer is an indiscriminate disease, affecting rich and poor, old and young. Still, Canadians’ odds of getting sick depend surprisingly on where they live.

Why we need a new war on cancer

Over-treating and over-screening is doing patients more harm than good

The issue: Advances in screening and diagnosis are sending some cancer patients down aggressive treatment paths that they shouldn’t be on.
The solution: A new war on cancer and a rethinking of resources.

Drug money

Some cancer treatments cost as much as $33,000 a month, but fall well short of being wonder cures

A Post analysis of 17 cancer drugs that cost between $4,700 and $33,000 a month reveals only three had evidence that they extended lives when approved by Health Canada.

Bankrupt by cancer

Cancer is not just a life-threatening disease ― but a financial disaster.

In Canada, a country that prides itself on looking after the sick, no matter their ability to pay, Canadians are declaring bankruptcy because of cancer.

The fundraising complex

Of the $2.7 billion that cancer charities spent in 2013, only 45 per cent went towards fighting cancer.

The Post’s analysis of cancer funding reveals the depth of inefficiencies in the sector. In 2013, more than half of total funds went to salaries and overhead.

Learning to live with cancer

As science gets better at controlling cancer for longer periods of time, it might be best to kill the battle rhetoric

Nowhere else in medicine is the battle rhetoric more entrenched than in cancer. And its defeating people. Who wants to go war with their own bodies?

Prevention as the ultimate cure

Prevention saves more lives than any cancer drug

However, in the multi-billion-dollar cancer business, efforts to stop people from contracting the illness account for as little as five per cent of what’s spent.

How to reduce your risk of becoming a breast cancer patient by one third

Dr Peter Gøtzsche’s views on breast cancer screening

Video published on 1 April 2015 by John McDougall.

Peter C. Gøtzsche, MD is a Danish medical researcher, and leader of the Nordic Cochrane Center at Rigshospitalet in Copenhagen, Denmark. He has written numerous reviews within the Cochrane collaboration.

Dr.Gøtzsche has been critical of screening for breast cancer using mammography, arguing that it cannot be justified; His critique stems from a meta-analysis he did on mammography screening studies and published as Is screening for breast cancer with mammography justifiable? in The Lancet in 2000. In it he discarded 6 out of 8 studies arguing their randomization was inadequate.

In 2006 a paper by Gøtzsche on mammography screening was electronically published in the European Journal of Cancer ahead of print. The journal later removed the paper completely from the journal website without any formal retraction. The paper was later published in Danish Medical Bulletin with a short note from the editor, and Gøtzsche and his coauthors commented on the unilateral retraction that the authors were not involved in.

In 2012 his book Mammography Screening: Truth, Lies and Controversy was published. In 2013 his book Deadly Medicines and Organized Crime: How Big Pharma has Corrupted Healthcare was published.

The Concern about Overdiagnosis

A clear insight about over diagnosis in less than 3 mns

Video published on 19 Nov 2016 by Show More Spine.

Paul Glasziou’s Interview by Alan Cassels at Preventing Overdiagnosis Conference 2016 in Barcelona, Spain.

Watch more videos about overdiagnosis on YouTube.

Breast cancer screening not associated with a reduction in the incidence of advanced cancer

Mammograms tied to overdiagnosis of breast cancer

The current study offers fresh evidence linking routine screening to over-diagnosis of non-aggressive tumors because it compares outcomes over a single time period in two regions of Denmark – one that offered biennial mammography for women aged 50 to 69 and one that didn’t.

January 2017 Study Abstract

Background
Effective breast cancer screening should detect early-stage cancer and prevent advanced disease.

Objective
To assess the association between screening and the size of detected tumors and to estimate overdiagnosis (detection of tumors that would not become clinically relevant).

Design
Cohort study.

Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis, Annals of Internal Medicine, DOI: 10.7326/M16-0270, 10 JANUARY 2017.

Philips Mammography Truck, Brazil via philips_newscenter.

Setting
Denmark from 1980 to 2010.

Participants
Women aged 35 to 84 years.

Intervention
Screening programs offering biennial mammography for women aged 50 to 69 years beginning in different regions at different times.

Measurements
Trends in the incidence of advanced (>20 mm) and nonadvanced (≤20 mm) breast cancer tumors in screened and nonscreened women were measured. Two approaches were used to estimate the amount of overdiagnosis: comparing the incidence of advance and nonadvanced tumors among women aged 50 to 84 years in screening and nonscreening areas; and comparing the incidence for nonadvanced tumors among women aged 35 to 49, 50 to 69, and 70 to 84 years in screening and nonscreening areas.

Results
Screening was not associated with lower incidence of advanced tumors. The incidence of nonadvanced tumors increased in the screening versus prescreening periods (incidence rate ratio, 1.49 [95% CI, 1.43 to 1.54]). The first estimation approach found that 271 invasive breast cancer tumors and 179 ductal carcinoma in situ (DCIS) lesions were overdiagnosed in 2010 (overdiagnosis rate of 24.4% [including DCIS] and 14.7% [excluding DCIS]). The second approach, which accounted for regional differences in women younger than the screening age, found that 711 invasive tumors and 180 cases of DCIS were overdiagnosed in 2010 (overdiagnosis rate of 48.3% [including DCIS] and 38.6% [excluding DCIS]).

Limitation
Regional differences complicate interpretation.

Conclusion
Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%).

Regular Mammograms Risk-Benefit Characterization Theater

Breast-Cancer and Mammography : Consider the Pros and Cons

How Tiny Are Benefits From Many Tests And Pills? Researchers Paint A Picture

Mammograms are said to cut the risk of dying from breast cancer by as much as 20 percent ; some researchers want people to question that kind of thinking.

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