Overdiagnosis in primary care: framing the problem and finding solutions

Abstract

Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians' and patients' lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians' understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.

Unravelling complexities of the subsolid pulmonary nodule—detection, characterization, natural history, monitoring and (future) patient management

“…This has taught us important lessons on pulmonary lesions that look like cancer and even have malignant cells in histology, but do not behave malignant. This observation is quite similar to indolent lesions in other organs (2).…”

Use of tests in UK primary care

“…Over-testing has many drivers—these include health system factors where, in fee-for-service health systems, financial or other incentives might inadvertently promote increased testing 34. Expanded disease definitions identify more previously healthy people as being unwell; a review of US clinical guidelines reported that for 10 of 16 guidelines studied, disease definitions had been widened 345.…”

“…Expanded disease definitions identify more previously healthy people as being unwell; a review of US clinical guidelines reported that for 10 of 16 guidelines studied, disease definitions had been widened 345. An example is the publication of new diagnostic criteria for chronic kidney disease on the basis of largely laboratory measurements of kidney function and damage 6.…”

“…. and the unnecessary fear that this can engender.”13 With escalating healthcare expenditure internationally, reducing over-testing represents an evidence based approach to decreasing costs without compromising health 4…”

Overdiagnosis: interpreting biochemistry results

“…Kale and Korenstein review overdiagnosis in primary care 1. We must remember that, when looking at a marginally raised biochemistry result, the reference range quoted is a 95% range.…”