Overdiagnosis of Disease

Hoffman, Jerome R.; Cooper, Richelle J.

doi:10.1001/archinternmed.2012.3319

Cited by 84 publications

(60 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…5,42,59 Physicians in our sample clearly acknowledged their fear of uncertainty, and most felt that improved training on diagnostic testing would be helpful. Toward this end, some excellent resources are available to EPs, including AEM Evidence-Based Diagnostics section, EvidenceBased Emergency Care textbook, 60 and www.thentt.com Web site, which provide systematic approaches to understanding diagnostic test utility for common ED diagnoses.…”

Section: Discussionmentioning

confidence: 97%

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Kanzaria

Hoffman

Probst

et al. 2015

Academic Emergency Medicine

Self Cite

171

146

View full text Add to dashboard Cite

Objectives: The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.Methods: As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.Results: In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). Conclusions:Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.ACADEMIC EMERGENCY MEDICINE 2015;22:390-398

show abstract

Section: Discussionmentioning

confidence: 97%

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Kanzaria

Hoffman

Probst

et al. 2015

Academic Emergency Medicine

Self Cite

171

146

View full text Add to dashboard Cite

show abstract

“…124,125 The current meta-analysis provides a quantitative framework upon which EM health care providers, educators, and policy-makers can build costeffectiveness models for the diagnosis of scaphoid fractures. A rigorous cost-effectiveness analysis incorporating the tenets of this article with appropriate medical and nonmedical costs could help redesign clinical management of the suspected scaphoid fracture in the ED.…”

Section: Discussionmentioning

confidence: 99%

Adult Scaphoid Fracture

Carpenter

Pines

Schuur

et al. 2014

Academic Emergency Medicine

View full text Add to dashboard Cite

ObjectivesScaphoid fractures are the most common carpal fracture, representing 70% of carpal bone fractures. The diagnostic accuracy of physical examination findings and emergency medicine (EM) imaging studies for scaphoid fracture has not been previously described in the EM literature. Plain x‐rays are insufficient to rule out scaphoid fractures in a patient with a suggestive mechanism and radial‐sided tenderness on physical examination. This study was a meta‐analysis of historical features, physical examination findings, and imaging studies for scaphoid fractures not visualized on plain x‐ray in adult emergency department (ED) patients, specifically to address which types of imaging tests should be recommended in patients with persistent concern for acute fracture after ED discharge.MethodsA medical librarian and two emergency physicians (EPs) conducted a medical literature search of PUBMED and EMBASE. The original studies' bibliographies were reviewed for additional references and unpublished manuscripts were located via a hand search of EM research abstracts from national meetings. All abstracts were independently reviewed by the two physicians, and Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS‐2) was used to assess individual study quality. When two or more qualitatively similar studies were identified, meta‐analysis was conducted using Meta‐DiSc software. Primary outcomes were sensitivity, specificity, and likelihood ratios (LRs) for predictors of scaphoid fracture detected on follow‐up in patients with normal ED x‐rays.ResultsA total of 957 unique citations were identified, yielding 75 studies eligible for inclusion in this systematic review. Studies were significantly heterogeneous in design, study population, and criterion standard. The majority of studies were conducted in non‐ED settings (e.g., orthopedic clinics). No studies used accepted diagnostic research publishing guidelines, and the overall QUADAS‐2 methodologic quality was low, indicating an increased risk of bias in the estimates of diagnostic accuracy. The prevalence of scaphoid fractures ranged from 12% to 57% with the point estimate of 25% pretest probability for adult ED patients with concern for scaphoid injuries, nondiagnostic index x‐rays, and scaphoid fractures on later imaging studies. Except for the absence of snuffbox tenderness (LR– = 0.15), physical examination findings lack accuracy to rule in or rule out scaphoid fractures, and no validated clinical decision rules exist. In patients with persistent concern for injury, magnetic resonance imaging (MRI) is superior to bone scan, computed tomography (CT), or ultrasound (US) to both rule in and rule out scaphoid fractures. Both MRI and CT share the added benefit of identifying alternative etiologies for posttraumatic wrist pain.ConclusionsExcept for the absence of snuffbox tenderness, which can significantly reduce the probability of scaphoid fracture, history and physical examination alone are inadequate to rule in or rule out scaphoid fracture. MRI is the most accurate imaging test to diagnose scaphoid fractures in ED patients with no evidence of fracture on initial x‐rays. If MRI is unavailable, CT is adequate to rule in scaphoid fractures, but inadequate for ruling out scaphoid fractures.

show abstract

“…combines significant overuse and to a lesser grade, underuse, although the level of inappropriateness differentiate depending on the clinical guidelines used 19 . The unnecessary management of overdiagnosed diseases seems to be an increasingly significant issue in clinical practice especially in developed countries 20,21 , with financial and personal effects 22,23 .…”

Section: Discussionmentioning

confidence: 99%