It's #PODC2015 time: Preventing Overdiagnosis 2015 is here

After an incredible General Council (the annual meeting of the Canadian Medical Association), it is now time for me to zip off to Bethesda, MD for Preventing Overdiagnosis.

Although I attended last year in Oxford, this will be my first time speaking at the conference; I have the fortune of working with Dr James Rickert (who challenges conflict of interest in orthopedics and puts the patient first) in order to present a workshop around some of the criticisms (and related solutions) for the Choosing Wisely campaign (at 11:30, Weds Sept 2nd).

I would say that I am Choosing Wisely's biggest fan, and biggest critic. I am looking forward to the opportunity to hear more thought from my peers about the campaign and what the next steps might entail. There is so much hope and opportunity with this initiative and it's a great time to strengthen it and to reach higher!

This conference will also be a great opportunity to reflect on the past couple of years and the progress that so many people have made, and to meet up with colleagues to hear about their planned work going forward. There will be quite a few curious and critical-thinking Canadians in attendance, including (I hear):

-   Dr. Laurent Marcoux (former head of the Quebec Medical Association, one of the key developers of their Action Plan for Overdiagnosis

-    Dr. Roland Grad (researcher in family practice currently looking at harnessing infoPOEMs to identify low-value tests and treatments)

-    Dr. Rita McCracken (finishing her PhD, an expert on polypharmacy/deprescribing in the elderly)

-    Dr. Tracy Monk (humble yet highly effective champion and practicer of patient centered, evidence-based, and relationship-based care)

-    Dr Alan Cassels (co-author of Selling Sickness and highly sensible drug policy researcher)

-    Joanna Trimble (family member and advocate for confronting polypharmacy and sedative overuse in the elderly, at Is Your Mom On Drugs?)

-    Dr. Danielle Martin (head of Canadian Doctors for Medicare and outspoken advocate for doing more with less)

-    Dr Sacha Bhatia (chair of evaluation and can-do pioneer for Choosing Wisely Canada)

-    Dr Jennifer Young (leader of the Don’t Just Do Something, Stand There workshop with the Ontario College of Family Practitioners)

Go Canada!

And that is just the tip of the iceberg. The entire conference will be comprised of like-minded peers from around the world. I can't wait to get started tomorrow; see you there!!!

 

Less is more, InVivo Magazine

in Vivo Magazine

in Vivo Magazine

In the spring, I had the pleasure of being one of many people interviewed by Julie Zaugg for In Vivo Magazine.

Their sixth issue featured Less is More with data and opinions from mainly Swiss physicians and researchers. 

From the by-line, it seems they've missed the idea entirely

People are beginning to speak out against over-medialization. Measures are being taken to encourage less care, even if that means giving up old certainties.

That sounds like doing less is a terrible idea! Fortunately, the article comprehensively features the benefits of taking this approach to care. Comfort with uncertainty is one trait that can make a good physician great. That piece explores the state of the 'overmedicalised world,' the causes for it, and what some of the remedies might be. My emphasis? Patient-centred care.

You can see the article here, or explore the whole issue on Issu. If you'd like to see other interviews, articles, or talks I have participated in, check out the Media section.

 

It was wonderful to be a small part of the article and because of my involvement, I learned about "Smarter Medicine," a Swiss campaign [in German and French] similar to Choosing Wisely;  I have a feeling that they two will be integrated in time. This and other projects around the world are featured on the ever-growing Projects page.

 

 

Source: http://www.invivomagazine.com/en/focus/chr...

Quaternary Prevention, P4

We still lack a unifying name, but initiatives like "Right Care," "Choosing Wisely," "Preventing Overdiagnosis," "Prudent Healthcare," and others all seek to describe, categorize, confront, or improve upon the status quo of what's being done: too much medical stuff and too little caring for people.

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    Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. International Journal of Health Policy and Management, 2015, 4(2), 61–64

 

Quaternary Prevention

You may have read lately about Quaternary Prevention (Prévention quaternaire) or P4, a major initiative of this movement. This – in the words of Ray Moynihan – "awkwardly titled" idea came originally from Dr Marc Jamoulle (@jamoulle), a Belgian GP, almost 30 years ago.

He coined the term "Quaternary Prevention" to describe 'an action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are ethically acceptable.' Essentially, it is a process that explicitly considers and thus enables avoidance of iatrogenic harm. 

"Quaternary prevention should take precedence over any alternative preventive, diagnostic and therapeutic, as dictated by the principle of primum non nocere." (Wikipedia)

P4

*NB*: Be careful not to confuse Jamoulle's term P4 with the more popular P4; predictive, preventive, personalized, and participatory (P4) medicine, with a focus on detecting and dealing with disease before it even exists, may (arguably) be the antithesis to Quaternary Prevention.

Jamoulle's idea came first, anyway. His original 1986 article Information and computerization in general practice (en français) started the discussion around quaternary prevention, with a particular focus on how information technology can dehumanize healthcare. He has refined the idea, with presentations at WONCA world conferences and many publications (listed here).

View Dr Jamoulle's page on Quaternary Prevention "P4" or read more

Although the cumbersome title will probably dissuade related initiatives from taking the name and falling under the umbrella of 'quaternary prevention,' we are all united in the spirit of our efforts. I remain in awe that Jamoulle and others had the wisdom to begin the discussion of harms of overdiagnosis in a time while mammography was just gaining momentum, ADD was rarely diagnosed and yet to be redefined as ADHD, and I was still in diapers.

Rational test ordering in family medicine

It is typical in medical teaching to start an article or talk with a case.

What is not typical about about this Canadian Family Physician (CFP) article, written by Australians Drs S Morgan, M van Driel, J Coleman, and P Magin, is that the case is not meant to teach us how to do something. It is meant to challenge us, to teach us how NOT to do something.

When a 'routine annual health check' involves non-evidenced tests, and abnormal results are found, it leads to further testing; anxiety and other harmful effects of the testing cascade or treatments develop. This is the problem of overtesting and overdiagnosis.

It is best to not order irrational, unjustified tests "just to see" because there are harms of "just seeing." If you order enough tests, there will definitely be abnormal findings, many of which are spurious or clinically insignificant.

Many of those reading know this problem, but we are not always sure of the solutions. Morgan et al suggest and expand upon these mitigating steps:

  • Undertake a thorough clinical assessment
  • Consider the probability and implications of a positive test result
  • Practise patient-centred care
  • Follow clinical guidelines or seek other specialist guidance (*my caveat: if the guidelines are reasonable, free of industry bias, and appropriate for the patient in front of you)
  • Do not order tests to reassure the patient
  • Accept a degree of uncertainty
  • Use serial rather than parallel testing
  • Reflect and critically appraise test ordering

I like the list as it challenges some myths, like "ordering the test will make the patient feel better." Many of the drivers of overtesting explained here overlap with the Contributing Factors piece I'm working on, though I'm inspired that perhaps "taking time" (using a longitudinal relationship to slow down, to do serial testing, etc.) may need to be added to the list.

View the article in the CFP to read more.



Source: http://www.cfp.ca/content/61/6/535?etoc

How Much Are We Over-Diagnosing Cancer?

The word about 'overdiagnosis' is a regular feature in medical journals, stories are found at least weekly in major newspapers, and patients are starting to question whether cancer screening tests are really right for them.

Victory!

Ok, no no, we are a long way from finding the right balance of too much and too little medicine. But now that we accept that 'too much medicine' is a real thing, we need to figure out just how big the problem is.

Peter Ubel (@peterubel) is a physician and behavioural scientist, and author of Critical Decisions (see this and related books on our list)

He has attempted to lay out the way in which we can quantify (and clarify) the times where we inappropriately give a person the label of 'cancer.'

He states clearly that misdiagnosis, while unfortunate, isn't overdiagnosis. He also says that false-positives, while they can lead to harmful results, are not overdiagnosis.

What is is then? Whole conferences (eg. Preventing Overdiagnosis) have been devoted to defining it. 

Overdiagnosis, according to Ubel, occurs when we detect things that would never have caused a problem for the patient. He gives the example of a tiny breast cancer that would never have been noticeable in an elderly woman (who would undoubtedly die of something else first). When trying to change the culture to encourage people to stay away from screening tests that will lead to overdiagnosis, we are up against several challenges. One of those is the fact that early diagnosis can sometimes make it seem like we live longer if we detect the cancer earlier, though finding it early doesn't improve or save our life (lead-time bias, which is explained in the article).

Ultimately, in order to quantify the prevalence of overdiagnosis, we will need population-level data after a screening program has been introduced, and the data will need to be measured for long enough that any of the lead time bias effect will have passed.

Read more of Dr Ubel's explanation, How Much Are We Over-Diagnosis Cancer? in Forbes.

Source: http://www.forbes.com/sites/peterubel/2015...

Choosing Wisely Canada: 3rd Wave of Reccomendations

Choosing Wisely Canada has released their 3rd wave of recommendations!

Groups like the Canadian Association of Emergency Physicians (CAEP), Canadian Society of Hospital Medicine (CSHM), three psychiatry groups (Canadian Academy of Child and Adolescent Psychiatry, Canadian Academy of Geriatric Psychiatry, Canadian Psychiatric Association) and three surgical groups (Canadian Spine Society, Canadian Society for Vascular Surgery) have all developed lists of the top things that patients and doctors should question. The Canadian Society for Transfusion Medicine also added 5 new recommendations. See the new recommendations here.

This round was particularly interesting for me as I got to witness the process of the development of the CSHM list and participate in some stages, though not extensively. It's a tough task, whittling down all the ideas to find well-evidenced items that represent key areas for improvement, and try to avoid duplication of other specialty society recommendations. The group has to consider that many things which are good ideas and really really important to tackle, may not be suitable as the evidence behind them may be vague.

For example, though we all felt that discussing 'goals of care' or advance directives and resuscitation statuses (eg. DNR) with patients is very important, there's little data about why/how/when this should happen and what impact it actually has on patient well-being. Should it be discussed by the hospitalist? The GP? On all admissions? Only when a patient's status changes?

Ultimately it was impossible to make a firm statement that was robustly rooted in evidence, though our 'gut' feeling was strongly that we need to be having these discussions and that patients and doctors both should be starting conversations on the subject.

Choosing Wisely, as ever, forms a great starting place for discussing overuse of harmful and unnecessary tests and treatments. Yes, some of the recommendations are 'low-hanging fruit' but we have to start somewhere, and Choosing Wisely is great at getting us started talking about the facts that "more is not always better" in medicine.

Source: http://www.choosingwisely.ca

BMJ Blogs: Six proposals for EBM’s future

Dr Paul Glasziou is a Professor of Evidence-Based Medicine at Bond University in Australia. He speaks and writes mainly about the translation of health research into clinical practice.

His latest contribution to the BMJ Blog is a look at the future of evidence-based medicine (EBM). As its era fades into another, it becomes apparent that there is still a huge gap between what research tells us and what doctors and patients wind up doing.

Sometimes the known evidence is biased, of poor quality, or doesn't actually have any relevance for our patient. Sometimes, we have strong evidence about what is clinically 'correct' but we have forgotten to remember that each patient is an individual, with unique goals and life circumstances. Sometimes, we get so caught up in chasing the potential benefits of something that we fail to realize it could be causing more harm than good.

Read Dr Glaszious' Six Proposals for EBM's future, as he tackles these tough issues and helps to guide us back to a place where research improves care.

Source: http://blogs.bmj.com/ce/2015/03/27/six-pro...

Addendum! Scholarships for Students to PODC2015! #overdiagnosis

For any students interested in attending Preventing Overdiagnosis 2015 in Bethesda, Maryland (near Washington DC), there are student registration rates and bursaries available!

It's an amazing opportunity to learn more, meet others studying/working/researching in this area, and to develop your own ideas.


Don't miss out:

We are pleased to be able to offer 50 reduced places for Medical and Health Science students. These places are available at a fee of £95 ($143) on a first come first served basis. During registration you will be asked to confirm your student status, please add your current role, organisation and student number if appropriate.

Bursary applications are being accepted. To apply please email a brief application using the following structure to info@preventingoverdiagnosis.net accompanied with a brief CV.
– Your current position and any work or experience in overdiagnosis or related areas
– How you would use what you learned from attending PODC2015, for future work?
– Your organisation and country

Closing date of midnight May 27th successful applicants informed w/c June 1st. Travel funds are still under review, successful applicants will be informed of full bursary cover at the time of notification.

Go to the main site, www.preventingoverdiagnosis.net to learn all about the conference.

Why Survival Rate Is Not the Best Way to Judge Cancer Spending

The New York Times has a great piece on their Upshot blog about assessing value when it comes to testing and treating cancer. It can be very challenging to measure whether the money we spend on health care is providing good return, making a meaningful improvement for patients.

We want every dollar we spend to help people live longer and higher-quality lives. However, when data of survival rate is examined, it may lead to inaccurate conclusions about the effectiveness and worth of a test or treatment.

The Upshot expands upon Why Survival Rate Is Not the Best Way to Judge Cancer Spending. Dr Carroll explains how statistics - particularly the parameter of 'survival rates' - can mislead us into thinking we are helping patients, but because of lead-time bias and overdiagnosis bias, what we are measuring as "success" is not actually translating into improvement for the patient. Our mis-guided spending is leading to the point where we do not have money to spend on more impactful interventions. 

Read the article for clear explanations of these biases with illustrative examples, and consider that by focussing on the wrong measures, "we may be getting far less for our money then we think."

Source: http://www.nytimes.com/2015/04/14/upshot/w...

VIDEO: "The values of clinical practice" Campaign for doctors in training

Thanks to the Advances in Clinical Management blog run by Dr Jordi Varela (@gesclinvarela), I discovered this video (in Catalan with english subtitles) highlighting key aspects of clinical practice that need to change in order to move us toward "the right care."

Dr Varela summarizes the key points of the video as follows:

  1. Learn to listen patients and appreciate what their circumstances are.

  2. Forget about persuasion and learn the technique of motivational interviewing.

  3. Help patients to make clinical decisions for themselves.

  4. Rate the burden of treatment and learn to deprescribe whenever necessary.

  5. Take the time for clinical reasoning and adopt the Bayesian probabilistic thinking.

  6. Request tests that make sense clinically, thinking about the value they will bring.

  7. Learn to teamwork, specially when facing complex patients.

  8. Watch out for overdiagnosis when practicing prevention and share it with target people.

  9. Incorporate palliative methodology in your clinical practice and know how to have the proper conversation about the end of life with patients and their families.

  10. Know how to get the "Right Care" sources.

Some of the top sources are listed at the end of the video and in the blog post. Check it out.

Source: http://varelaclinicalmanagement.blogspot.c...