Overdiagnosis: its rise, causes, and possible cures Professor Paul Glasziou NHMRC Australia Fellow...
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![Page 1: Overdiagnosis: its rise, causes, and possible cures Professor Paul Glasziou NHMRC Australia Fellow Bond University Paul_Glasziou@bond.edu.au Private Healthcare.](https://reader035.fdocuments.us/reader035/viewer/2022081515/56649e215503460f94b0d27f/html5/thumbnails/1.jpg)
Overdiagnosis: its rise, causes, and possible curesProfessor Paul GlasziouNHMRC Australia FellowBond University [email protected]
Private Healthcare Australia Conference 2015
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My Background: Researcher & GP
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Growth in health care spending: Most is more and better (hospital) services
More, and expanded1.Usage of Tests2.Usage of Treatments3.Definitions of Disease (Overdiagnosis)
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Medical advances increase Life Expectancy by 3 Months/Year
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Types of Overdiagnosis
A. Over-detection, e.g, cancer screening, incidental MRI findings, etc
B. Expanded definitions, e.g, Diabetes, CKD, ADHD,
C. Medicalization, e.g, “female sexual dysfunction”, hypotrichosis,
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A. Overdetection: thyroid cancerThyroid cancer tripled in 25 years; no more deaths
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A. Overdetection: 4 cancers
An epidemic of diagnosis, not an epidemic of cancer!
Prostate Cancer Thyroid Cancer
Breast Cancer Melanoma
Source: AIHW
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Incidental findings with MRI of head
Prevalence (%)
NNS
Arachnoid cyst 0.5 200
Aneurysm 0.35 286
Meningioma 0.3 345
CCM 0.16 625
AVM 0.05 2,000
Low grade glioma
0.05 2,000Victims of Modern Imaging Technology BMJ 2009;339:b3016
Frequency of incidental findings with MRI of head: a meta-analysis
For most, treatment is not needed or is harmful.SIGN Guidelines suggest: “DO NOT do MRI unless …”
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Incidentalomas in MRI of spine
0102030405060708090
100
20-29 30-39 40-49 50-59 >60
% of asymptomatic patients with MRI
Disc Bulge Disc Protrusion
Jensen MC, NEJM, 1994
Disc protrusion in 24 year old with no back pain
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Too much testing?
“A normal person is someone who has not had enough tests” - Dean at John Hopkins Medical School
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B. Expanding definitions of Diabetes
US Prevalence by age Change of Definition
2003 ADA update
Impact of Definition Changes on:•Trial interpretation, eg UKPDS•Risk Scores, eg Framingham
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A Tale of Two GDM Definitions New criteria for diagnosing
Gestational Diabetes (GDM) by International Association of Diabetes in Pregnancy Study Group (IADPSG)
Increase GDM diagnoses from 6% (WHO) to 18% (IADPSG)
Cost extra $US2.5 billion/year Based on risk of adverse outcome NO evidence treatment of
new cases improve outcomes
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Osteoporosis: Prevalence for changed definition
M. Brooke Herndon et al. Health Aff 2007;26:1702-1711
©2007 by Project HOPE - The People-to-People Health Foundation, Inc.
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Of 16 publications on 14 common conditions, 10 widened and 1 narrowed definitions.
Widen by 3 methods: (i) ‘‘pre-disease’’; (ii) lowering thresholds; (iii) earlier or new diagnostic methods.
None had rigorous assessment of potential harms of proposed changes.
The average proportion of members with industry ties was 75%; 12/16 chairs had ties.
CONCLUSION:“research and policy attention might be directed at designing new processes for reviewing disease definitions, free of financial conflicts of interest and informed by rigorous analysis of benefits and harms.”
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C. Medicalization
Then you might have“Body Dysmorphic Disorder by Proxy”
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Saving Normal
Allen Frances, Chair DSM IV
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Why does Overdiagnosis matter?
Too much testing of well people and not enough care for the sick worsens health inequalities and drains professionalism, harming both those who need treatment and those who don’t.”
Margaret McCartney, GP Glasgow, Author of “The Patient Paradox”.
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What can we do?
1. Raise awareness 2. Inform patients of pros & cons3. Guidelines for disease definitions4. Invest in research & policy initiatives5. …
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1 Raise Awareness: #Overdiagnosis
2013 Dartmouth2014 Oxford2015 Washington
(Launch in April, 6 Colleges)
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2 Inform patients of pros and cons Patients overestimate benefits and
underestimate harms (of screening, treatments, etc)
Informing patients often dampens enthusiasm
Two processes For individuals: shared decision making For policy: community juries
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3 Guidelines for disease definitions
Guidelines being developed by GIN, GRADE, WHO collaboration
1-day Meeting: August 2014 Position paper: 2015
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4 Invest in research & policy initiatives
“Our combined resources are a few $million, but for those promoting overdiagnosis it is $billions. It is a David and Goliath struggle.”
Allen Frances Chair DSM IV
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What can we do?
1. Raise awareness 2. Inform patients of pros & cons3. Guidelines for disease definitions4. Invest in research & policy initiatives5. …
[email protected] www.crebp.net.au