Overtesting and the Downstream Consequences of Overtreatment: Implications of “Preventing Overdiagnosis” for Emergency Medicine

Abstract

Overtesting, the downstream consequences of overdiagnosis, and overtreatment of some patients are topics of growing debate within emergency medicine (EM). The "Preventing Overdiagnosis" conference, hosted by The Dartmouth Institute for Health Policy and Clinical Practice, with sponsorship from consumer organizations, medical journals, and academic institutions, is evidence of an expanding interest in this topic. However, EM represents a compellingly unique environment, with increased decision density tied to high stakes for patients and providers with missed or delayed diagnoses in a professional atmosphere that does not tolerate mistakes. This article reviews the relevance of this reductionist paradigm to EM, provides a first-hand synopsis of the first "Preventing Overdiagnosis" conference, and assesses barriers to moving the concept of less test ordering to reality.

Mapping the drivers of overdiagnosis to potential solutions

“…Building on existing initiatives, we hope this analysis will help offer a suite of possible solutions to those seeking to reduce iatrogenic harm and enhance health system sustainability. Beliefs: "More is better," "new is better," "early is better," "wants to know/screen"-even if currently healthy, imperative of possibility (we have to test because we can) 3- 17 -24 More healthy scepticism on the benefits of early diagnosis especially in populations less likely to benefit Faith in early diagnosis or detection and prevention is better than cure, fear of diagnosis missed or made too late 3- 27 -29 Address intolerance of uncertainty 22 Intolerance of uncertainty and error 8-28 -30 NA Medicalisation of life; fear of ageing, sickness, or death 9-22 - [25][26][27][28][29][30][31] Improve media reporting, journalist training, campaigns about overdiagnosis and overuse 2-28…”

“…Avoid certain tests or screening tests 11 35 Less frequent screening tests Targeted screening tests (eg, limit screening to well defined high risk population) 9-35 - [37][38][39][40] Inform patients of benefits and harms of screening 3-36 Raise threshold for "positive" screen or recall and biopsy [26][27][28][29][30][31][32][33][34][35][36][37][38][39] Change radiological advice 35 …”

“…Drawing from the field of ecological economics to frame overdiagnosis as overconsumption , Hensher and colleagues call for "a more rigorous application of the precautionary principle" in technology assessment to avoid giving "potentially harmful overuse the benefit of the doubt." 12 Other potential solutions include stronger regulation of the advertising of new tests and treatments to the public and health professionals 30 and paying greater attention to managing and reducing conflicts of interest with industry. 47 …”

“…Avoid certain tests or screening tests 11 35 Less frequent screening tests Targeted screening tests (eg, limit screening to well defined high risk population) 9-35 - [37][38][39][40] Inform patients of benefits and harms of screening Raise threshold for "positive" screen or recall and biopsy [26][27][28][29][30][31][32][33][34][35][36][37][38][39] Change radiological advice drivers of overdiagnosis and overuse 9 23 overdiagnosis and overuse frequency and best methods to quantify the problem undiagnosing and deprescribing 3 deliberative and qualitative methods (including community juries) to inform policy and other decisions [23][24][25][26][27][28][29][30][31][32][33][34][35][36] evaluating responses to overuse, including communication …”

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda

“…47 The priority questions that remain for the education of older ED patients are as follows: 48 With annual expenditures on medical imaging approaching $100 billion in the United States, 49 recent efforts have focused on reducing diagnostic testing in situations when risks of testing are likely to outweigh benefits. 50 In addition to being high-cost, diagnostic tests sometimes have little to no effect on treatment or patient quality of life, and their results may lead to unnecessary treatments and associated complications. 51 Overuse of diagnostic imaging is particularly common for conditions that disproportionately affect older adults, such as back pain.…”