Jack O’Sullivan

Overdiagnosis: what it is and what it isn’t

> Why then, can one desire too much of a good thing?n> n> William Shakespeare, As You Like It (1600)nRosalind’s question, as she is about to marry Orlando, is purely rhetorical—she thinks that one cannot desire too much of a good thing. Nevertheless, trite though it may be, it is true that one can sometimes have it. It is certainly true of healthcare and has been referred to as ‘too much medicine’,1 although because of potential confusion with ‘too much medication’ a better term might be ‘too much healthcare’. This includes too much screening of asymptomatic individuals, too much investigation of those with symptoms, too much reliance on biomarkers, too many quasi-diseases, too much diagnosis, often leading to too much treatment, sometimes cost-ineffective, medicines that are too costly and too rapidly approved for marketing, too many adverse reactions, and too much inappropriate monitoring. And too much healthcare implies too little effective healthcare.nnAn older term, ‘overdiagnosis’ has been used to refer to a more restricted set of items. And although the term can be traced back as far as 1955,2 it is still difficult to define satisfactorily.nnBroadly, overdiagnosis means making people patients unnecessarily, by identifying problems that were never going to cause harm or by medicalising ordinary life experiences through expanded definitions of diseases.nnOverdiagnosis has two major causes: overdetection and overdefinition of disease. While the forms of overdiagnosis differ, the consequences are the same: diagnoses that ultimately cause more harm than benefit. Confusion about what constitutes overdiagnosis undermines progress to a solution. Here we aim to draw boundaries around what overdiagnosis is and to exclude what it is not.nnOverdetection refers to the identification of abnormalities that were never going to cause harm, abnormalities that do not progress, that progress too slowly to cause symptoms or harm during a person’s remaining lifetime, or that …

Overtesting and undertesting in primary care: a systematic review and meta-analysis

Background Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. Objective To identify overuse and underuse of diagnostic tests in primary care. Design Systematic review and meta-analysis. Data sources and eligibility criteria We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. Results We included 357u2009171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests. The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%–100%)%). 17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%–78%, n=8). Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%–92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%–54% (n=10) and 8%–52% (n=2), respectively. Conclusions There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO registration number CRD42016048832.

Prevalence and outcomes of incidental imaging findings: umbrella review

Abstract Objective To provide an overview of the evidence on prevalence and outcomes of incidental imaging findings. Design Umbrella review of systematic reviews. Data sources Searches of MEDLINE, EMBASE up to August 2017; screening of references in included papers. Eligibility criteria Criteria included systematic reviews and meta-analyses of observational studies that gave a prevalence of incidental abnormalities (“incidentalomas”). An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or an imaging abnormality in a symptomatic patient, where the abnormality was not apparently related to the patient’s symptoms. Primary studies that measured the prevalence of incidentalomas in patients with a history of malignancy were also considered in sensitivity analyses. Results 20 systematic reviews (240 primary studies) were identified from 7098 references from the database search. Fifteen systematic reviews provided data to quantify the prevalence of incidentalomas, whereas 18 provided data to quantify the outcomes of incidentalomas (13 provided both). The prevalence of incidentalomas varied substantially between imaging tests; it was less than 5% for chest computed tomography for incidental pulmonary embolism in patients with and without cancer and whole body positron emission tomography (PET) or PET/computed tomography (for patients with and without cancer). Conversely, incidentalomas occurred in more than a third of images in cardiac magnetic resonance imaging (MRI), chest computed tomography (for incidentalomas of thorax, abdomen, spine, or heart), and computed tomography colonoscopy (for extra-colonic incidentalomas). Intermediate rates occurred with MRI of the spine (22%) and brain (22%). The rate of malignancy in incidentalomas varied substantially between organs; the prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland. Extra-colonic, prostatic, and colonic incidentalomas were malignant between 10% and 20% of the time, whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%). Many assessments had high between-study heterogeneity (15 of 20 meta-analyses with I2 >50%). Conclusions There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs. This umbrella review will aid clinicians and patients weigh up the pros and cons of requesting imaging scans and will help with management decisions after an incidentaloma diagnosis. Our results can underpin the creation of guidelines to assist these decisions. Systematic review registration PROSPERO: CRD42017075679.

Ten essential papers for the practice of evidence-based medicine

In this article we signpost readers to 10 papers we consider essential reading for anyone starting out on an evidence-based medicine journey. We have considered papers consisting a mix of old and new, seminal and cutting-edge that offer insight into what evidence-based medicine is, where it came from, why it matters and what it has achieved. This is balanced against some of the common criticisms of evidence-based medicine and efforts to tackle them. We have also highlighted papers acknowledging the importance of teaching and learning of the principles of evidence-based medicine and how health professionals can better use evidence in clinical decisions with patients.

Suicide attempts in people taking isotretinoin for acne

Are increased, but the risk is difficult to separate from the higher risk associated with the condition itself

Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments.

BackgroundRates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement.MethodsThis was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines.ResultsWe identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics).ConclusionsWe identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.

Author Correction: Variation in diagnostic test requests and outcomes: a preliminary metric for OpenPathology.net

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

Has too much cardiology been sent into the appropriateness ORBITA

The 2017,xa0the Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina (ORBITA) trial by Al-Lamee et al 1 was the first double-blind, randomised, sham-controlled trial to investigate the role of percutaneous coronary intervention (PCI) for the treatment of stable angina. It showed no significant difference in exercise tolerance between patients treated with a shamxa0procedure (placebo) and with PCI. Further, patients who underwent PCI had no improvements in other exercise outcomes, nor with any patient-reported endpoints. The results from the ORBITA trial have important implications for clinical practice and research.nnThe ORBITA trial questioned what has now become routine clinical practice, namely PCI for patients with stable angina. The results suggest that patients who undergo PCI for stable angina accept a small, but not insignificant, risk of harm for no benefit. It is hard to imagine a scenario where a fullyxa0informed patient would …

Controversies in PSA screening

Forty years after its discovery, a reanalysis of the two largest trials to date, controversially suggests that prostate-specific antigenxa0(PSA) screening may actually be beneficial.nnMost healthcare organisations do not recommend PSA screening for prostate cancer,1 2 mainly in response to conflicting evidence about the benefits and clear evidence of harms. PSA can lead to false positive or ‘overdiagnosed’ cancer (detecting prostate cells that histologically represent cancer, but will never grow to cause a patient harm).nnEvidence regarding efficacy has been based on two large randomised controlled trials: The European Randomised Study of Screening for Prostate Cancer (ERSPC)3 and Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO).4 These trials are both considered to be of high quality, but the trials came to …