Issue 40 / 15 October 2018

“FIRST, do no harm” is an axiom known to all doctors, so a significant shift toward overdiagnosis has prompted some of Australia’s leading clinicians and researchers to form an alliance with consumer and public organisations to tackle the complex drivers behind this trend.

In a Perspective piece in this week’s MJA , members of the Wiser Healthcare research collaboration have outlined their plan for a national response to tackle overdiagnosis, which, they say, is leading to harms from unnecessary disease labels and treatments, as well as wasted health care resources.

As outlined in the MJA article, overdiagnosis is common across a wide range of conditions, including thyroid cancer, pulmonary embolism, attention deficit/hyperactivity disorder and pre-diabetes.

Lead author Dr Ray Moynihan said overdiagnosis was a deep, cultural problem.

“Overdiagnosis is often the result of the best of intentions, so dealing with it is going to be complicated,” said Dr Moynihan, who is a senior research fellow at Bond University’s Centre for Research in Evidence-based Practice.

“For an individual working doctor, it’s not at all clear how to address this problem of overdiagnosis, but that’s part of why we are working with [professional] colleges and other groups to try and [deal with] this issue slowly, carefully, safely and fairly,” he told MJA InSight.

The Wiser Healthcare initiative was formed after last year’s National Summit on Overdiagnosis. The summit resulted in the publication of a short Initial Statement to underpin the development of a National Action Plan to Prevent Overdiagnosis and Overtreatment in Australia.

In preparing a national plan, the Wiser Healthcare collaboration has identified a range of possible drivers and potential solutions to overdiagnosis, covering issues relating to culture, professionals, the health system, industry and technology, and the public.

Co-author Professor Rachelle Buchbinder said a multipronged approach to the issue was essential.

“You can’t just address one driver because it won’t work,” she said. “You have to try to have a systems approach so that efforts are not wasted because of other drivers that might prevent the change.”

Professor Buchbinder, Director of the Monash Department of Clinical Epidemiology, said it was important to engage patients as well as clinicians in the process of change.

“Part of the problem is the pushback from patients, so we need to educate patients about the possible harms of testing,” she said. “People think ‘it’s just a test’, without recognising that the test could lead to downstream harm by being inappropriately interpreted or leading to more invasive treatment.”

It’s a message that Professor Buchbinder and international colleagues highlighted in a series on low back pain in The Lancet earlier this year. Featuring a call to action to reduce many of the common but ineffective interventions for low back pain, the series attracted prominent media attention internationally and resulted in 15 million Twitter impressions in the days after publication.

Professor Buchbinder said such an approach was well aligned with the Wiser Healthcare strategy.

“The Lancet series came about because we were really worried about iatrogenic harm and overtreatment, which meant that people were missing out on effective medical care as well,” Professor Buchbinder said. “The problems are around too much bad care, but not enough good care as well.”

She said widening disease definitions across all of medicine were also responsible for increasing rates of overdiagnosis.

“The most recent examples have been pre-hypertension, pre-diabetes, and then gestational diabetes,” she said. “I understand the desire to detect disease earlier to prevent long term complications but, again, people need to be aware of the unintended consequences of labelling people who may have a risk factor, but don’t really have a disease.”

Professor Buchbinder said increasingly sensitive technology used in cancer screening was also enabling the detection of smaller abnormalities with sometimes questionable significance. The MJA authors pointed to 2016 research that found that more than 500 000 people may have been overdiagnosed with thyroid cancer across 12 nations over 20 years.

“The potential harmful consequences of more sensitive diagnostic tests need to be considered along with their benefits,” Professor Buchbinder said.

Dr Moynihan said early detection had become a double-edged sword, and was a particularly challenging issue to address in the time-pressured environment of general practice

“Explaining to patients that early detection is not always the best medicine is a complex and difficult task,” he said. “[Early detection] can carry many benefits for many people, but sometimes it means we are turning people into patients unnecessarily.”

Dr Moynihan said that, in his many presentations about overdiagnosis around Australia in recent years, GPs had been a particularly engaged audience.

“GPs see the problem of too much medicine first hand,” he told MJA InSight. “They see their patients often being unnecessarily medicalised, unnecessarily labelled in expanded disease definitions, and often view part of their role as protecting [their patients] from unnecessary diagnosis and treatment.”

Dr Moynihan said efforts needed to turn to reframing reassurance, as it is often an “incredibly valuable” therapeutic option.

The Wiser Healthcare initiative joins existing programs in Australia seeking to reduce overdiagnosis and the use of low value care, such as Choosing Wisely, the Royal Australasian College of Physicians’ EVOLVE initiative, and the Australian Commission on Safety and Quality in Health Care’s Atlas of Healthcare Variation. A review of the Medicare Benefits Schedule is also under way.

Chair of the Choosing Wisely Australia Advisory Group Dr Matthew Anstey said representatives of the initiative and its facilitator, NPS MedicineWise, had participated in the initial Wiser Healthcare strategy day.

“That reflects the fact that Choosing Wisely and the overdiagnosis movement are both looking to reduce harm to patients from unnecessary tests, treatments and procedures, and are very aligned in our directions,” Dr Anstey said.

He said Choosing Wisely Australia, which was supported by 80% of Australian medical colleges, was seeking to provide clinicians with evidence-based and colleague-endorsed recommendations of tests, treatments and procedures that should be questioned.

“This gives structure to clinicians, allowing them to do less and explain to their patient that a certain treatment is not supported by evidence and their colleagues all agree,” he said.

Patients too were being encouraged to question interventions, with Choosing Wisely promoting five questions that consumers can ask about the harms and benefits of tests.

“Choosing Wisely is looking to partner with consumers to increase their awareness of the downsides of too many [tests and interventions], or too much intensity of health care.”

Dr Moynihan said there were significant challenges in tackling the many forces driving overdiagnosis in Australia, and a continuing focus on safety and equality was key.

“Whatever we do, we want to do it safely and fairly,” he said. “We don’t want to increase inequities in the system and we don’t want to increase harm, but the evidence suggests there is an imperative to act here. We can’t just ignore the problem of overdiagnosis because it’s too difficult.”

 

15 thoughts on “Overdiagnosis: a deep cultural problem

  1. jennifer bromberger says:

    I am more concerned about over diagnosis of psychiatric illness and then the overprescription of medications.. and this is in a diagnostic testing vacuum.

  2. Anonymous says:

    As a medical practitioner myself and having been subjected to a very inappropriate labelling of convenience, I have found it impossible to get the labelling overturned. The harm it has caused to myself and my family has been horrendous. Indeed the labelling effects had snowballed to the point where I decided to take my own life.
    The labelling could have been avoided if an adequate and honest assessment been performed at the outset. I implore all those who have integrity to attempt to uphold the importance of a proper clinical assessment to avoid others being subjected to the same fate as myself.

  3. Calochilus says:

    Overdiagnosis of psychiatric disorders is demonstrably a furphy. The climbing rate of suicide and the escalating presentation of people in psychological distress to EDs is sufficient testament to that. Going on the Gov’t own acknowledged figures, the prevalence of ADHD in children is around 7.8%, the actual diagnostic rate is less than half of that and the actual treatment rate less than one quarter. The prevalence in middle aged adults is over 6% (Das et al)
    What is missing is the concept of early intervention that prevents ADHD, anxiety and depression from leading to far more serious outcomes. Lack of time constrains further comment.

  4. Professor Jane Andrews says:

    Another regulatory issue which will need addressing if we limit over-investigation and over-diagnosis, is minimising the medico-legal risk to individual Drs who limit testing according to evidence and then miss pathology. We know this will happen, and yet, we cannot afford to practice “fear-based” medicine, it costs and harms more than limiting tests/diagnoses – however there will still be individual cases where patients feeling aggrieved when they have a “late” diagnosis…… Are our “legal colleagues” and regulators “at the same table” on this??

    If not, time to invite them to be part of the solution.

  5. CC says:

    maybe.
    but tell that to the lawyers who sue for failing to diagnose early cancer….

  6. Dr John Stokes says:

    There is a cascade in medicine that reinforces this activity in both medicine and surgery. We are taught we should prevent disease; and so we say ok let us test for all these “preventable” diseases; ok then we conclude we should treat what we find; this feels good to us all so we ask why don’t we test more of the population; well we can do that for just about any disease now (even if the tests are poor or non specific); the treatments may only help a minority, mayn’t help many and can cause complications in others; the rewards though are to the doctor (he/she is considered thorough by the patient and earns more), the patient is rewarded (someone cares about them and mostly it is free and gets a false sense of security), many organisations (hospitals, charities, researches, drug companies, pathology companies and imaging groups) get more govt, insurance and donated money. Then it goes we could do this earlier, that would be a good idea particularly if we can lable it pre-disease. The sequence is circular and reinforcing. The thinking doctor is now considered uncaring, lazy and worse if he misses anything no matter how irrelevant he/she is incompetent and needs reeducation, being sued or being suspended. The number of unnecessary investigations in our hospitals now almost certainly outnumbers the necessary tests done. For many number in need of investigation, number needed to treat, number that are harmed by unnecessary treatment in the name of prevention, and the redirection of our scarce resources from proven interventions and therapies does not come into the equation.

  7. Anonymous says:

    “Choosing Wisely Australia, …..is supported by 80% of Australian medical colleges…”, and a great many other health, community and government organisations as well. The Australian and New Zealand College of Psychiatrists is conspicuous by its absence.
    Some argue that psychiatry is the specialty in which over-diagnosis and over-reliance on physical treatments are most endemic. I’m a psychiatrist. If the RANZCP could bring itself to openly support Choosing Wisely, that might help our public image.

  8. Anonymous says:

    In support of J. Bromberger and psychiatric overdiagnoses, this is a big problem for Western Society.
    I have had long service as a military doctor and am alarmed at the high rate of PTSD diagnoses in Australian service personnel : much higher incidence than our American , British partners even though the latter have seen more action in Iraq & Afghanistan (i.e.higher casualty rate). The drivers appear to be a low diagnostic threshold applied by psychologists & psychiatrists using check-list diagnostic matrices and the generous financial incentives for therapists and their clients ( eg DVA TPI pension is $ 700 a week tax-free + generous benefits). Many of the patients I have seen have a depressive disorder ( endogenous or reactive) or generalized anxiety disorder, but who would want these labels when they do not compensate very well. I have had a naïve civilian psychologist try to convince me I have PTSD when I most definitely do not. We should treat patients, not financially seduce them and their therapists with cash prizes.

  9. Dr Shane O'Dea says:

    As a paediatrician, I am highly concerned about two recent trends – the blatant over diagnosis of Autism Spectrum Disorder and psychiatric diagnoses such as anxiety, depression, OCD, and many others in increasingly younger children. The diagnosis itself can have many harmful results, such as social stigma, preconceptions, overshadowing the personality/individuality of the child, a permanent “past history” of mental health diagnosis that may affect later eligibility for insurance purposes, etc. Of greater concern is the frequency of medication use with a paucity of evidence to support their safety and efficacy.

    Parents of children with definite, severe “real” autism find it difficult to accept the use of this diagnosis in children who would previously have been said to be “shy” or “quirky”. The enormous financial cost to our community alone should be enough justification to urgently address this phenomenon of over diagnosis.

    It is refreshing to see that there is an understanding of good intention on the part of doctors and that parents and patients must be involved in the education process in order to address this issue. In the case of autism and psychiatric diagnoses in children, allied health professionals and psychologists must also be involved as I feel they play a key role in diagnosis.

    Finally, a move away from diagnosis based government funding to needs based funding is another vital element in reducing the spectre of over diagnosis. The NDIS was supposed to focus on needs and function, but unfortunately it seems to be going down the path of emphasising diagnosis as I feared it would.

  10. Anonymous says:

    Researches, as we know from Dr. John Ioannidis who has spent his career challenging his peers by exposing their bad science, up to 80 to 90 per cent of researches are flawed. This isn’t something that has been fixed from the time I first read this article here: https://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/308269/

    In addition we know that in the medical profession (as well as other professions – government is a good example) a re-frame to sound helpful can have another agenda altogether. To take items off the medicare listing to make it more sustainable as the population is ageing could be one such example.

    I sympathise with Anonymous – mud sticks even when it is found to be wrong. Another example is the witch-hunt – where despite their best efforts the Australian Health Practitioner Regulation Agency (AHPRA) have failed to silence Dr Gary Fettke. After being subjected to 4½ years of bullying and harassment, AHPRA have finally dropped all charges. More than that, its made a public apology to Dr Fettke following a review of his case. https://www.ahpra.gov.au/News/2016-11-16-media-statement.aspx So why wasn’t an honest assessment performed at the outset and how has this affected the doctor’s mental, physical and spiritual wellbeing?

    Another example is the medical on line health card. Some doctors see that as ‘Big Brother is watching you,’ wanting to get information about what doctors are doing, prescribing and what else – through the back door of the online system??? There are other safer alternatives that the government could be making but are just not interested in looking at – one has to ask why?

    It is propaganda to say that any on-line system could be made safe. This is supported by new information from Gemalto who report that there have been 4.6 billion records breaches in the first half of 2018 – an increase of 133 per cent over the first half of 2017.

    And yes, I agree with jennifer bromberger’s concerns in the labelling and over prescription of medications and diagnosis of psychiatric illness.

    Is it any wonder I read the above article with scepticism?

  11. Dr Roger Wilson says:

    The current Populist political trend to pour more and more money into ” Mental Health” is in danger of promoting more and more “Victimhood ” within the Australian community and runs the risk of doing harm. It already appears that even at school level labels of anxiety, depression ,ADHD and other psychopathological labels are being cast around in an attempt to treat a perceived epidemic of youth mental illness which then may carried forth into adulthood. While not wishing to deny the possibility of genuine mental illness I wish there could be more emphasis on teaching resilience at the earliest possible age. The political and public sphere has been taken over by progressives who wish to protect the young and population in general from the slings and arrows of failure and hardship when failure itself should be the starting point in building character and resilience. It is OK to fail and failure should not lead to mental illness if there is proper mentoring. Mentoring at parent and teacher level should be the goal not labels and prescriptions. Sadly we are becoming a mollycoddled society where at every turn victimhood is promoted and everyone must get a prize for just turning up else they suffer “psychological damage”. I believe that mental health is turning into an industry with the definite risk of doing harm.
    As the father of a son with schizophrenia I would dearly love to receive more help than we do in regard to severe mental and psychotic conditions but the current “Headspace” trend I fear will produce nothing but over diagnosis and prescribing when teaching resilience and perhaps on many occasions “tough love ” would serve the individual much better in preparation for the real world.

  12. Anonymous says:

    Has someone caught up with anonymous from the medical sphere 🙁 ?
    If that person is suicidal perhaps they should not remain anonymous .

  13. Anonymous says:

    A paediatrician’s view – key areas
    1.Over diagnosis in sub acute and chronic settings.
    2.Questionable explanation and referrals and management discussions in ED settings and areas where role substitution is prevalent .
    3.NDIS and the confusion.

    1. The seed is planted about a potential diagnosis by many well meaning carers. Early childhood worker, Primary school teacher. Community Nurse even Allied Health professionals. How many of them are using the standardised screening tools. How many are familiar with the tools. Is the undergraduate training of respective course equipping them to understand the pathogenesis and the heterogeneity of clinical presentation of developmental and behavioural disorders such as ASD, ADHD, Dyslexia etc.
    Who is regulating the course? Who is reviewing the standards of such workers? Any outside body with overall knowledge and understanding of the issues involved?
    To my knowledge it is often an “Educator” from within the craft group.
    The parent visits the GP or the Paediatrician because of the concerns raised by one of the above. In a minority of cases the parents themselves identify some deviations from the norm in their child’s development and behaviour and seek guidance from the health professionals.

    Is such cases included as over diagnosis (need quality studies to prove) or a symptom of many failures from all involved in providing care and education to parents? Diminishing parenting skills tied up with time, resources and finances in the background of intense lobbying for funding (diagnosis based and disability based) has led to the perceived over diagnosis?

    2. Policies and procedures are mushrooming every minute in public and private, acute and non-acute health system. Pathways are popular to minimise waiting time and early discharge. All these under the pre text of “safe practice”, “clinical governance”. Once a child has been identified by a health professional as “suspected” of a condition the clinical reasoning in the wards become a real challenge. For example every vomiting child will be gastroenteritis. Every wheeze in a child is asthma and Ventolin is trialled in ED. Viral urticarial rash referred to the allergy clinic, improper urine sample showing leucocytes and protein are commenced on antibiotics for UTI. Are we classifying these as “over diagnosis” or “differential diagnosis”? I would consider these as poor clinical management.
    The number of “tongue tie”, “lip tie” release performed by health workers has gone up by 300% as per MJA article 2 months ago. Exclusively breastfeeding babies with weight loss of more than 10% of birth weight often do not see a doctor as they are deemed “sufficient” breast feeding. Is this over diagnosis as well?

    3. The issues around NDIS throws another dimension into this issue of “over diagnosis”.
    Health professionals are not directly involved in the functionality of NDIS.
    It is a goal based and need based funding which is orchestrated by a different body. The Ministry of Health is not a signatory nor is the health professionals namely the medical profession renumerated for this through this fund. However lately the NDIS is directing the parents of children over 6 years to get a report with the diagnosis to determine the funding eligibility and funding. Most Paediatricians who work outside the hospital based multidisciplinary team setting with children with developmental and behavioural difficulties confront this situation frequently. It is interesting to note that anecdotal evidence is mounting among practising paediatricians outside hospital settings that children who were funded by NDIS when they were under 6 years of age are now being referred to the Paediatricians to make a diagnosis. The psychologists who have been involved in therapy for a longer period often choose to refrain from a diagnostic approach even though they are renumerated to make certain diagnosis. Example – ASD on DSM-V.
    This is certainly influencing the picture and the statistics about over diagnosis.

  14. Anonymous says:

    Thank you.

  15. T K Wong says:

    I agree with the views of reply 4, 6, and 11.
    Common sense should prevail
    Get “dogmatism” out of the practice of medicine!

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