Jenny Doust

Preventing overdiagnosis: How to stop harming the healthy

Evidence is mounting that medicine is harming healthy people through ever earlier detection and ever wider definition of disease. With the announcement of an international conference to improve understanding of the problem of overdiagnosis, Ray Moynihan, Jenny Doust, and David Henry examine its causes and explore solutions

Information from pharmaceutical companies and the quality, quantity, and cost of physicians' prescribing: A systematic review

Geoff Spurling and colleagues report findings of a systematic review looking at the relationship between exposure to promotional material from pharmaceutical companies and the quality, quantity, and cost of prescribing. They fail to find evidence of improvements in prescribing after exposure, and find some evidence of an association with higher prescribing frequency, higher costs, or lower prescribing quality.

Prevalence of attention-deficit/ Hyperactivity disorder: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE: Overdiagnosis and underdiagnosis of attention-deficit/hyperactivity disorder (ADHD) are widely debated, fueled by variations in prevalence estimates across countries, time, and broadening diagnostic criteria. We conducted a meta-analysis to: establish a benchmark pooled prevalence for ADHD; examine whether estimates have increased with publication of different editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM); and explore the effect of study features on prevalence. METHODS: Medline, PsycINFO, CINAHL, Embase, and Web of Science were searched for studies with point prevalence estimates of ADHD. We included studies of children that used the diagnostic criteria from DSM-III, DSM-III-R and DSM-IV in any language. Data were extracted on sampling procedure, sample characteristics, assessors, measures, and whether full or partial criteria were met. RESULTS: The 175 eligible studies included 179 ADHD prevalence estimates with an overall pooled estimate of 7.2% (95% confidence interval: 6.7 to 7.8), and no statistically significant difference between DSM editions. In multivariable analyses, prevalence estimates for ADHD were lower when using the revised third edition of the DSM compared with the fourth edition (P = .03) and when studies were conducted in Europe compared with North America (P = .04). Few studies used population sampling with random selection. Most were from single towns or regions, thus limiting generalizability. CONCLUSIONS: Our review provides a benchmark prevalence estimate for ADHD. If population estimates of ADHD diagnoses exceed our estimate, then overdiagnosis may have occurred for some children. If fewer, then underdiagnosis may have occurred.

Political drive to screen for pre-dementia: Not evidence based and ignores the harms of diagnosis

#### Summary box Current policy in many countries is aimed at increasing the rates of diagnosis of dementia and cognitive impairment.1 2 …

Chronic kidney disease controversy: how expanding definitions are unnecessarily labelling many people as diseased

#### Summary box In 2002 the United States Kidney Foundation launched a novel framework for defining and classifying chronic kidney disease.1 The framework was widely embraced because it imposed order in a chaotic landscape characterised by a variety of names, including renal insufficiency, renal impairment, and renal failure. It has had an appreciable effect on clinical care worldwide through guidelines,2 pay for performance measures, …

The challenge of overdiagnosis begins with its definition

Overdiagnosis means different things to different people. S M Carter and colleagues argue that we should use a broad term such as too much medicine for advocacy and develop precise, case by case definitions of overdiagnosis for research and clinical purposes

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

A survey of resilience, burnout, and tolerance of uncertainty in Australian general practice registrars

BackgroundBurnout and intolerance of uncertainty have been linked to low job satisfaction and lower quality patient care. While resilience is related to these concepts, no study has examined these three concepts in a cohort of doctors. The objective of this study was to measure resilience, burnout, compassion satisfaction, personal meaning in patient care and intolerance of uncertainty in Australian general practice (GP) registrars.MethodsWe conducted a paper-based cross-sectional survey of GP registrars in Australia from June to July 2010, recruited from a newsletter item or registrar education events. Survey measures included the Resilience Scale-14, a single-item scale for burnout, Professional Quality of Life (ProQOL) scale, Personal Meaning in Patient Care scale, Intolerance of Uncertainty-12 scale, and Physician Response to Uncertainty scale.Results128 GP registrars responded (response rate 90%). Fourteen percent of registrars were found to be at risk of burnout using the single-item scale for burnout, but none met the criteria for burnout using the ProQOL scale. Secondary traumatic stress, general intolerance of uncertainty, anxiety due to clinical uncertainty and reluctance to disclose uncertainty to patients were associated with being at higher risk of burnout, but sex, age, practice location, training duration, years since graduation, and reluctance to disclose uncertainty to physicians were not.Only ten percent of registrars had high resilience scores. Resilience was positively associated with compassion satisfaction and personal meaning in patient care. Resilience was negatively associated with burnout, secondary traumatic stress, inhibitory anxiety, general intolerance to uncertainty, concern about bad outcomes and reluctance to disclose uncertainty to patients.ConclusionsGP registrars in this survey showed a lower level of burnout than in other recent surveys of the broader junior doctor population in both Australia and overseas. Resilience was also lower than might be expected of a satisfied and professionally successful cohort.

When financial incentives do more good than harm: a checklist

Financial incentives can sometimes improve the quality of clinical practice, but they may also be an expensive distraction. Paul Glasziou and colleagues have devised a checklist to help prevent their premature or inappropriate implementation

Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol

Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge.