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Huang L, Hu J, Cai Q, Ye A, Chen Y, Yang Xiao-zhi Z, Liu Y, Zheng J, Meng Z. Preliminary discrimination and evaluation of clinical application value of ChatGPT4o in bone tumors. J Bone Oncol 2024; 48:100632. [PMID: 39310381 PMCID: PMC11414679 DOI: 10.1016/j.jbo.2024.100632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/22/2024] [Accepted: 08/27/2024] [Indexed: 09/25/2024] Open
Abstract
•Evaluation of making up ChatGPT4o in the preliminary pathological diagnosis of bone tumors.•ChatGPT-4o's proficiency in analyzing pathological images and providing initial diagnoses of bone tumor characteristics is comparable to that of senior pathologists in the Tertiary hospital doctors group, with both surpassing the Remote grassroots doctors group.•AI, like ChatGPT-4o, has the potential to enhance diagnostic capabilities for remote grassroots doctors and improve sensitivity to reduce missed diagnosis rates among tertiary hospital doctors in identifying bone tumors.
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Affiliation(s)
- Leiyun Huang
- Medical College, Kunming University of Science and Technology, Kunming, China
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, Kunming, China
- Key Laboratory of Digital Orthopedics of Yunnan Province, Kunming, China
- Clinical Medicine Research Center of Orthopedics and Sports Rehabilitation in Yunnan Province, Kunming, China
- Clinical Medical Center for Spinal Cord Diseases in Yunnan Province, Kunming, China
| | - Jinghan Hu
- People’s Hospital of Wenshan Prefecture, the Affiliated Hospital of Kunming University of Science and Technology, Wenshan, China
| | - Qingjin Cai
- Department of Urology, Urologic Surgery Center, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing 400037, China
| | - Aoran Ye
- Department of Pain, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Yanxiong Chen
- Medical College, Kunming University of Science and Technology, Kunming, China
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, Kunming, China
- Key Laboratory of Digital Orthopedics of Yunnan Province, Kunming, China
- Clinical Medicine Research Center of Orthopedics and Sports Rehabilitation in Yunnan Province, Kunming, China
- Clinical Medical Center for Spinal Cord Diseases in Yunnan Province, Kunming, China
| | - Zha Yang Xiao-zhi
- Medical College, Kunming University of Science and Technology, Kunming, China
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, Kunming, China
- Key Laboratory of Digital Orthopedics of Yunnan Province, Kunming, China
- Clinical Medicine Research Center of Orthopedics and Sports Rehabilitation in Yunnan Province, Kunming, China
- Clinical Medical Center for Spinal Cord Diseases in Yunnan Province, Kunming, China
| | - Yongzhen Liu
- People’s Hospital of Wenshan Prefecture, the Affiliated Hospital of Kunming University of Science and Technology, Wenshan, China
| | - Ji Zheng
- Department of Urology, Urologic Surgery Center, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing 400037, China
| | - Zengdong Meng
- Medical College, Kunming University of Science and Technology, Kunming, China
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, Kunming, China
- Key Laboratory of Digital Orthopedics of Yunnan Province, Kunming, China
- Clinical Medicine Research Center of Orthopedics and Sports Rehabilitation in Yunnan Province, Kunming, China
- Clinical Medical Center for Spinal Cord Diseases in Yunnan Province, Kunming, China
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Sanders S, Barratt A, Buchbinder R, Doust J, Kazda L, Jones M, Glasziou P, Bell K. Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework. J Clin Epidemiol 2024; 165:111215. [PMID: 37952702 DOI: 10.1016/j.jclinepi.2023.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions. STUDY DESIGN AND SETTING We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis. RESULTS Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy. CONCLUSION Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.
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Affiliation(s)
- Sharon Sanders
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia.
| | - Alexandra Barratt
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3800, Australia
| | - Jenny Doust
- Centre for Longitudinal and Life Course Research, School of Public Health, University of Queensland, Herston, Queensland 4006, Australia
| | - Luise Kazda
- NHMRC Healthy Environments And Lives (HEAL) National Research Network, National Centre for Epidemiology and Population Health, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory 2601, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland 4229, Australia
| | - Katy Bell
- Sydney School of Public Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
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Bell KJL, Zhu L, Glasziou P. Keeping Score-Appropriate and Timely Use of CACS-Reply. JAMA Intern Med 2022; 182:1233-1234. [PMID: 36066888 DOI: 10.1001/jamainternmed.2022.3826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Katy J L Bell
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lin Zhu
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
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Johannessen TR, Halvorsen S, Atar D, Munkhaugen J, Nore AK, Wisløff T, Vallersnes OM. Cost-effectiveness of a rule-out algorithm of acute myocardial infarction in low-risk patients: emergency primary care versus hospital setting. BMC Health Serv Res 2022; 22:1274. [PMID: 36271364 PMCID: PMC9587629 DOI: 10.1186/s12913-022-08697-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
Aims Hospital admissions of patients with chest pain considered as low risk for acute coronary syndrome contribute to increased costs and crowding in the emergency departments. This study aims to estimate the cost-effectiveness of assessing these patients in a primary care emergency setting, using the European Society of Cardiology (ESC) 0/1-h algorithm for high-sensitivity cardiac troponin T, compared to routine hospital management. Methods A cost-effectiveness analysis was conducted. For the primary care estimates, costs and health care expenditure from the observational OUT-ACS (One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome) study were compared with anonymous extracted administrative data on low-risk patients at a large general hospital in Norway. Patients discharged home after the hs-cTnT assessment were defined as low risk in the primary care cohort. In the hospital setting, the low-risk group comprised patients discharged with a non-specific chest pain diagnosis (ICD-10 codes R07.4 and Z03.5). Loss of health related to a potential increase in acute myocardial infarctions the following 30-days was estimated. The primary outcome measure was the costs per quality-adjusted life year (QALY) of applying the ESC 0/1-h algorithm in primary care. The secondary outcomes were health care costs and length of stay in the two settings. Results Differences in costs comprise personnel and laboratory costs of applying the algorithm at primary care level (€192) and expenses related to ambulance transports and complete hospital costs for low-risk patients admitted to hospital (€1986). Additional diagnostic procedures were performed in 31.9% (181/567) of the low-risk hospital cohort. The estimated reduction in health care cost when using the 0/1-h algorithm outside of hospital was €1794 per low-risk patient, with a mean decrease in length of stay of 18.9 h. These numbers result in an average per-person QALY gain of 0.0005. Increased QALY and decreased costs indicate that the primary care approach is clearly cost-effective. Conclusion Using the ESC 0/1-h algorithm in low-risk patients in emergency primary care appears to be cost-effective compared to standard hospital management, with an extensive reduction in costs and length of stay per patient.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08697-6.
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Affiliation(s)
- Tonje R Johannessen
- Department of General Practice, Institute of Health and Society, University of Oslo, 1130 Blindern, 0318, Oslo, NO, Norway. .,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway.
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - John Munkhaugen
- Department of Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne Kathrine Nore
- Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | - Torbjørn Wisløff
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Odd Martin Vallersnes
- Department of General Practice, Institute of Health and Society, University of Oslo, 1130 Blindern, 0318, Oslo, NO, Norway.,Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
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McKinn S, Batcup C, Cornell S, Freeman N, Doust J, Bell KJL, Figtree GA, Bonner C. Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11705. [PMID: 36141978 PMCID: PMC9517328 DOI: 10.3390/ijerph191811705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.
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Affiliation(s)
- Shannon McKinn
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
| | - Carys Batcup
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
| | - Samuel Cornell
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
| | - Natasha Freeman
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
| | - Jenny Doust
- Australian Women and Girls’ Health Research Centre, School of Public Health, University of Queensland, Brisbane 4006, Australia
| | - Katy J. L. Bell
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
| | - Gemma A. Figtree
- Kolling Institute, University of Sydney, St Leonards 2065, Australia
| | - Carissa Bonner
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney 2006, Australia
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Breth-Petersen M, Bell K, Pickles K, McGain F, McAlister S, Barratt A. Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare. BMJ Open 2022; 12:e056997. [PMID: 35998953 PMCID: PMC9472108 DOI: 10.1136/bmjopen-2021-056997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 06/30/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing. DESIGN Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis. SETTING Australian healthcare system. PARTICIPANTS Population of Australia. OUTCOME MEASURES We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO2e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses. RESULTS There were a total of 4 457 657 Medicare-funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018-2019 total. From our literature review, 76.5% of Australia's vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO2e, equivalent to driving ~160 000-230 000 km in a standard passenger car. CONCLUSIONS Unnecessary vitamin D testing contributes to avoidable CO2e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant.
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Affiliation(s)
| | - Katy Bell
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kristen Pickles
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Forbes McGain
- Department of Critical Care, The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
| | - Scott McAlister
- Department of Critical Care, The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Alexandra Barratt
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Bell KJL, White S, Hassan O, Zhu L, Scott AM, Clark J, Glasziou P. Evaluation of the Incremental Value of a Coronary Artery Calcium Score Beyond Traditional Cardiovascular Risk Assessment: A Systematic Review and Meta-analysis. JAMA Intern Med 2022; 182:634-642. [PMID: 35467692 PMCID: PMC9039826 DOI: 10.1001/jamainternmed.2022.1262] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Coronary artery calcium scores (CACS) are used to help assess patients' cardiovascular status and risk. However, their best use in risk assessment beyond traditional cardiovascular factors in primary prevention is uncertain. OBJECTIVE To find, assess, and synthesize all cohort studies that assessed the incremental gain from the addition of a CACS to a standard cardiovascular disease (CVD) risk calculator (or CVD risk factors for a standard calculator), that is, comparing CVD risk score plus CACS with CVD risk score alone. EVIDENCE REVIEW Eligible studies needed to be cohort studies in primary prevention populations that used 1 of the CVD risk calculators recommended by national guidelines (Framingham Risk Score, QRISK, pooled cohort equation, NZ PREDICT, NORRISK, or SCORE) and assessed and reported incremental discrimination with CACS for estimating the risk of a future cardiovascular event. FINDINGS From 2772 records screened, 6 eligible cohort studies were identified (with 1043 CVD events in 17 961 unique participants) from the US (n = 3), the Netherlands (n = 1), Germany (n = 1), and South Korea (n = 1). Studies varied in size from 470 to 5185 participants (range of mean [SD] ages, 50 [10] to 75.1 [7.3] years; 38.4%-59.4% were women). The C statistic for the CVD risk models without CACS ranged from 0.693 (95% CI, 0.661-0.726) to 0.80. The pooled gain in C statistic from adding CACS was 0.036 (95% CI, 0.020-0.052). Among participants classified as being at low risk by the risk score and reclassified as at intermediate or high risk by CACS, 85.5% (65 of 76) to 96.4% (349 of 362) did not have a CVD event during follow-up (range, 5.1-10.0 years). Among participants classified as being at high risk by the risk score and reclassified as being at low risk by CACS, 91.4% (202 of 221) to 99.2% (502 of 506) did not have a CVD event during follow-up. CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found that the CACS appears to add some further discrimination to the traditional CVD risk assessment equations used in these studies, which appears to be relatively consistent across studies. However, the modest gain may often be outweighed by costs, rates of incidental findings, and radiation risks. Although the CACS may have a role for refining risk assessment in selected patients, which patients would benefit remains unclear. At present, no evidence suggests that adding CACS to traditional risk scores provides clinical benefit.
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Affiliation(s)
- Katy J L Bell
- School of Public Health, University of Sydney, Sydney, Australia
| | - Sam White
- School of Public Health, University of Sydney, Sydney, Australia
| | - Omar Hassan
- School of Public Health, University of Sydney, Sydney, Australia
| | - Lin Zhu
- School of Public Health, University of Sydney, Sydney, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
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A novel methodological framework was described for detecting and quantifying overdiagnosis. J Clin Epidemiol 2022; 148:146-159. [PMID: 35483550 DOI: 10.1016/j.jclinepi.2022.04.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Methods to quantify overdiagnosis of screen detected cancer have been developed, but methods for quantifying overdiagnosis of non-cancer conditions (whether symptomatic or asymptomatic) have been lacking. We aimed to develop a methodological framework for quantifying overdiagnosis that may be used for asymptomatic or symptomatic conditions, and used Gestational Diabetes Mellitus as an example of how it may be applied. STUDY DESIGN AND SETTING We identify two earlier definitions for overdiagnosis, a narrower prognosis-based definition, and a wider utility-based definition. Building on the central importance of the concepts of prognostic information and clinical utility of a diagnosis, we consider the following questions: within a target population, do people found to have a disease using one diagnostic strategy but found not to have the disease using another diagnostic strategy (so called 'additional diagnoses'), have an increased risk of adverse clinical outcomes without treatment (prognosis evidence), and/or a decreased risk of adverse outcomes with treatment (utility evidence)? RESULTS Using Causal Directed Acyclic Graphs and Fair Umpires, we illuminate the relationships between diagnostics strategies and the frequency of overdiagnosis. We then use the example of Gestational Diabetes Mellitus to demonstrate how the Fair Umpire framework may be applied to estimate overdiagnosis. CONCLUSION Our framework may be used to quantify overdiagnosis in non-cancer conditions (and in cancer conditions), as well as to guide further studies on this topic.
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Khan E, Lambrakis K, Nazir SA, Chuang A, Halabi A, Tiver K, Briffa T, Cullen LA, Horsfall M, French JK, Sun BC, Chew DP. Implementation of more sensitive cardiac troponin T assay in a state-wide health service. Int J Cardiol 2022; 347:66-72. [PMID: 34774641 DOI: 10.1016/j.ijcard.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/30/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
AIMS Explore the impact of deploying high-sensitivity (hs) cardiac troponin T (cTnT) assay across a state-wide health service. METHODS AND RESULTS Presentations to emergency departments of six tertiary hospitals between January 2008 and August 2019 were included; standard cTnT assay was superseded by hs-cTnT in June 2011 without changing the reference range (≥30 ng/L reported as elevated), despite cTnT level of 30 ng/L being equivalent to ∼44 ng/L with hs-cTnT. Clinical outcomes were captured using state-wide linked health records. Interrupted time series analyses were used adjusted for seasonality and multiple co-morbidities using propensity score matching allowing for correlation within hospitals. In total, 614,847 presentations had ≥1 troponin measurement. Clinical ordering of troponin decreased throughout the study with no increase in elevated measurements amongst those tested with hs-cTnT. Small but statistically significant changes in index myocardial infarction (MI) diagnosis (-0.36%/year, 95%CI [confidence interval]:-0.48, -0.24,p < 0.001) and invasive coronary angiography (0.12%/year,95%CI:0, 0.24,p = 0.02) were seen, with no impact on death/MI at 30 days or 3-year survival in episodes of care (EOCs) with elevated cTnT after hs-cTnT implementation. Length of stay (LOS) was shorter among those with an elevated hs-cTnT (-4.44 h/year, 95%CI:-5.27, -3.60, p < 0.001). Non-elevated cTnT EOCs demonstrated shorter total LOS and improved 3-year survival (adjusted hazard ratio:0.90, 95%CI:0.83, 0.97,p = 0.008) although death/MI at 30 days was unchanged using hs-cTnT. CONCLUSION Widespread implementation of hs-cTnT without altering clinical thresholds reported to clinicians provided significantly shorter LOS without a clinically significant impact on clinical outcomes. A safer cohort with non-elevated cTnT was identified by hs-cTnT compared to the standard cTnT assay.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Sheraz A Nazir
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, Coventry, CV2 2DX, UK; Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health for Research (NIHR) Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QF, UK
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Amera Halabi
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kathryn Tiver
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
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White S, Gong H, Zhu L, Doust J, Loh TP, Lord S, Andrea ARH, McGeechan K, Bell K. Simulations found within-subject measurement variation in glycaemic measures may cause overdiagnosis of prediabetes and diabetes. J Clin Epidemiol 2021; 145:20-28. [DOI: 10.1016/j.jclinepi.2021.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/09/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
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Ma T, Semsarian CR, Barratt A, Parker L, Kumarasinghe MP, Bell KJL, Nickel B. Rethinking Low-Risk Papillary Thyroid Cancers < 1cm (Papillary Microcarcinomas): An Evidence Review for Recalibrating Diagnostic Thresholds and/or Alternative Labels. Thyroid 2021; 31:1626-1638. [PMID: 34470465 DOI: 10.1089/thy.2021.0274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Recalibrating diagnostic thresholds or using alternative labels may mitigate overdiagnosis and overtreatment of papillary microcarcinoma (mPTC). We aimed at identifying and collating relevant epidemiological evidence on mPTC, to assess the case for recalibration and/or new labels. Methods: We searched EMBASE and PubMed databases from inception to December 2020 for natural history, autopsy, diagnostic drift, and diagnostic reproducibility studies. Where a relevant systematic review was pre-identified, only new articles were additionally included. Non-English articles were excluded. One author screened titles and abstracts. Two authors screened full text articles, performed quality assessments, and extracted data. We undertook narrative synthesis of included evidence (pooled estimates from systematic reviews and single estimates from primary studies). Results: One systematic review of patients undergoing active surveillance found that after 5 years of follow-up, 5.3% (95% confidence interval [CI 4.4-6.4%]) of the mPTC lesions had increased in size by ≥3 mm, and 1.6% [CI 1.1-2.4%] of patients had lymph node metastases. Among 7 new primary studies (including 3 updates on 2 studies included in the systematic review), 1-5% of patients undergoing active surveillance had lymph node metastases after a median follow-up of 1-10 years. One systematic review found that subclinical thyroid cancer incidentally discovered at autopsy is relatively common, with a pooled prevalence of 11.2% [CI 6.7-16.1%] among studies that examined the whole thyroid. Four diagnostic drift studies evaluated the new classification of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Three studies of cases previously diagnosed as papillary thyroid cancer found 1.3-2.3% were reclassified as NIFTP (reclassifications were from follicular variation of papillary thyroid cancer [FVPTC]). One study of 48 cases previously diagnosed as mPTC found that 23.5% were reclassified as NIFTP. Thirteen reproducibility studies of papillary thyroid lesions found substantial variation in the histopathological diagnosis of thyroid lesions, including FVPTC and NIFTP classifications (no study evaluated mPTC). Conclusions: This review supports consideration of recalibrating diagnostic thresholds and/or alternative labels for low-risk mPTC.
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Affiliation(s)
- Tara Ma
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Caitlin R Semsarian
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Parker
- Charles Perkins Centre, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Marian Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
- Discipline of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Katy J L Bell
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Affiliation(s)
- Alexandra Barratt
- Wiser Healthcare and School of Public Health, University of Sydney, Australia
| | - Forbes McGain
- Department of Anaesthesia and Intensive Care, Western Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Australia; School of Public Health, University of Sydney, Australia
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O'Keeffe M, Nickel B, Dakin T, Maher CG, Albarqouni L, McCaffery K, Barratt A, Moynihan R. Journalists' views on media coverage of medical tests and overdiagnosis: a qualitative study. BMJ Open 2021; 11:e043991. [PMID: 34078634 PMCID: PMC8173287 DOI: 10.1136/bmjopen-2020-043991] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Promotional media coverage of early detection tests is an important driver of overdiagnosis. Following research evidence that global media coverage presents the benefits of testing healthy people far more frequently than harms, and gives little coverage to overdiagnosis, we sought to examine journalists' views on media reporting of tests, overdiagnosis, and strategies to improve critical reporting on tests. DESIGN Qualitative study using semistructured telephone interviews. Interviews were conducted between February and March 2020 and were audiorecorded and transcribed verbatim. Framework thematic analysis was used to analyse the data. PARTICIPANTS AND SETTING Twenty-two journalists (mainly specialising in health reporting, average 14.5 years' experience) based in Australia. RESULTS This sample of journalists acknowledged the potential harms of medical tests but felt that knowledge of harms was low among journalists and the public at large. Most were aware of the term overdiagnosis, but commonly felt that it is challenging to both understand and communicate in light of strong beliefs in the benefits of early detection. Journalists felt that newsworthiness in the form of major public health impact was the key ingredient for stories about medical tests. The journalists acknowledged that factors, like the press release and 'click bait culture' in particular, can influence the framing of coverage about tests. Lack of knowledge and training, as well as time pressures, were perceived to be the main barriers to critical reporting on tests. Journalists felt that training and better access to information about potential harms would enable more critical reporting. CONCLUSIONS Effectively communicating overdiagnosis is a challenge in light of common beliefs about the benefits of testing and the culture of current journalism practices. Providing journalists with training, support and better access to information about potential harms of tests could aid critical reporting of tests.
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Affiliation(s)
- Mary O'Keeffe
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Thomas Dakin
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ray Moynihan
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
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Reply. J Hypertens 2021; 39:1045-1046. [PMID: 33824261 DOI: 10.1097/hjh.0000000000002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review. JAMA Netw Open 2021; 4:e215335. [PMID: 33843998 PMCID: PMC8042533 DOI: 10.1001/jamanetworkopen.2021.5335] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services. OBJECTIVE To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions. EVIDENCE REVIEW This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality. FINDINGS Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms. CONCLUSIONS AND RELEVANCE This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.
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Affiliation(s)
- Luise Kazda
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Katy Bell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rae Thomas
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Kevin McGeechan
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rebecca Sims
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Alexandra Barratt
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Bell K, Doust J, McGeechan K, Horvath AR, Barratt A, Hayen A, Semsarian C, Irwig L. The potential for overdiagnosis and underdiagnosis because of blood pressure variability: a comparison of the 2017 ACC/AHA, 2018 ESC/ESH and 2019 NICE hypertension guidelines. J Hypertens 2021; 39:236-242. [PMID: 32773652 PMCID: PMC7810411 DOI: 10.1097/hjh.0000000000002614] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the extent that BP measurement variability may drive over- and underdiagnosis of 'hypertension' when measurements are made according to current guidelines. METHODS Using data from the National Health and Nutrition Examination Survey and empirical estimates of within-person variability, we simulated annual SBP measurement sets for 1 000 000 patients over 5 years. For each measurement set, we used an average of multiple readings, as recommended by guidelines. RESULTS The mean true SBP for the simulated population was 118.8 mmHg with a standard deviation of 17.5 mmHg. The proportion overdiagnosed with 'hypertension' after five sets of office or nonoffice measurements using the 2017 American College of Cardiology guideline was 3-5% for people with a true SBP less than 120 mmHg, and 65-72% for people with a true SBP 120-130 mmHg. These proportions were less than 1% and 14-33% using the 2018 European Society of Hypertension and 2019 National Institute for Health and Care Excellence guidelines (true SBP <120 and 120-130 mmHg, respectively). The proportion underdiagnosed with 'hypertension' was less than 3% for people with true SBP at least 140 mmHg after one set of office or nonoffice measurements using the 2017 American College of Cardiology guideline, and less than 18% using the other two guidelines. CONCLUSION More people are at risk of overdiagnosis under the 2017 American College of Cardiology guideline than the other two guidelines, even if nonoffice measurements are used. Making clinical decisions about cardiovascular prediction based primarily on absolute risk, minimizes the impact of blood pressure variability on overdiagnosis.
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Affiliation(s)
- Katy Bell
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
| | - Jenny Doust
- New South Wales Health Pathology, Department of Clinical Chemistry and Endocrinology
| | - Kevin McGeechan
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
| | | | - Alexandra Barratt
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
| | - Andrew Hayen
- Australian Centre for Public and Population Health Research, University of Technology Sydney (UTS)
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Les Irwig
- School of Public Health, Faculty of Medicine and Health, The University of Sydney
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Lam JH, Pickles K, Stanaway FF, Bell KJL. Why clinicians overtest: development of a thematic framework. BMC Health Serv Res 2020; 20:1011. [PMID: 33148242 PMCID: PMC7643462 DOI: 10.1186/s12913-020-05844-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests. METHODS Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development. RESULTS The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.
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Affiliation(s)
- Justin H Lam
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia.
| | - Kristen Pickles
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Fiona F Stanaway
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Katy J L Bell
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
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Burgstaller JM, Held U, Gravestock I, Klauser BS, Gort LM, Melzer L, Hasler S, Bierreth TD, Müller SE, Steurer J, Wertli MM. Impact of the Introduction of High-Sensitive Troponin Assay in the Emergency Department: A Retrospective Study. Am J Med 2020; 133:976-985. [PMID: 31987803 DOI: 10.1016/j.amjmed.2019.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/21/2019] [Accepted: 12/24/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Compared with troponin T/I test, the introduction of a high-sensitive (hs) troponin test may result in a higher proportion of positive test results in patients with chest pain and over-testing in patients without acute coronary syndrome. We assessed the impact of the introduction of the hs-troponin assay on the discharge diagnoses and the number of diagnostic tests in patients presenting with chest pain in a real-life setting in an emergency department. METHODS Retrospective chart review of patients presenting with chest pain to one of the largest hospitals in Switzerland. We compared the standard troponin period (December 2009 to November 2010) with the hs-troponin period (December 2010 to December 2011). RESULTS Data from 1274 patients (standard 597 [46.9%], hs-troponin 677 [53.1%]) were analyzed. The proportion of patients with non-ST-segment elevation myocardial infarction increased (hs-troponin 14.9%, compared with 9.7%); the proportion in unstable angina (1.5% to 4.0%) and other cardiac illnesses (8.1% to 11.7%) decreased. Although the proportion of noncardiac chest pain illnesses (67%) remained unchanged, the proportion of positive hs-troponin was higher (6.1% vs 2.0%). The average number of additional tests/person decreased in troponin-positive patients (2.0 to 1.7 test per patient; P = .02) and troponin-negative patients (3.1 to 2.8 tests; P < .0001). CONCLUSION Although the introduction of the hs-troponin test resulted in a higher proportion of positive hs-troponin tests in patients with noncardiac chest pain, the average number of diagnostic tests decreased in patients with chest pain presenting to an emergency department, indicating an increased confidence of clinicians in their diagnosis.
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Affiliation(s)
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer; Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Switzerland
| | - Isaac Gravestock
- Horten Centre for Patient Oriented Research and Knowledge Transfer
| | | | - Laura M Gort
- Horten Centre for Patient Oriented Research and Knowledge Transfer
| | - Lina Melzer
- Horten Centre for Patient Oriented Research and Knowledge Transfer
| | - Susann Hasler
- Division of General Internal Medicine, Kantonsspital Winterthur, Winterthur, Switzerland; University Hospital Zurich, University of Zurich, Switzerland
| | | | - Sarah E Müller
- Horten Centre for Patient Oriented Research and Knowledge Transfer
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer
| | - Maria M Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer; Division of General Internal Medicine, Bern University Hospital, University of Bern, Switzerland.
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McAlister S, Barratt AL, Bell KJ, McGain F. The carbon footprint of pathology testing. Med J Aust 2020; 212:377-382. [PMID: 32304240 DOI: 10.5694/mja2.50583] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/25/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To estimate the carbon footprint of five common hospital pathology tests: full blood examination; urea and electrolyte levels; coagulation profile; C-reactive protein concentration; and arterial blood gases. DESIGN, SETTING Prospective life cycle assessment of five pathology tests in two university-affiliated health services in Melbourne. We included all consumables and associated waste for venepuncture and laboratory analyses, and electricity and water use for laboratory analyses. MAIN OUTCOME MEASURE Greenhouse gas footprint, measured in carbon dioxide equivalent (CO2 e) emissions. RESULTS CO2 e emissions for haematology tests were 82 g/test (95% CI, 73-91 g/test) for coagulation profile and 116 g/test (95% CI, 101-135 g/test) for full blood examination. CO2 e emissions for biochemical tests were 0.5 g/test CO2 e (95% CI, 0.4-0.6 g/test) for C-reactive protein (low because typically ordered with urea and electrolyte assessment), 49 g/test (95% CI, 45-53 g/test) for arterial blood gas assessment, and 99 g/test (95% CI, 84-113 g/test) for urea and electrolyte assessment. Most CO2 e emissions were associated with sample collection (range, 60% for full blood examination to 95% for coagulation profile); emissions attributable to laboratory reagents and power use were much smaller. CONCLUSION The carbon footprint of common pathology tests was dominated by those of sample collection and phlebotomy. Although the carbon footprints were small, millions of tests are performed each year in Australia, and reducing unnecessary testing will be the most effective approach to reducing the carbon footprint of pathology. Together with the detrimental health and economic effects of unnecessary testing, our environmental findings should further motivate clinicians to test wisely.
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Affiliation(s)
| | | | - Katy Jl Bell
- Sydney School of Public Health, University of Sydney, Sydney, NSW
| | - Forbes McGain
- The University of Melbourne, Melbourne, VIC.,Western Health, Melbourne, VIC
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Bell KJL, Semsarian C, Doust J. Why We Might Not Need to Stress About Ruling Out Inducible Myocardial Ischemia. Ann Intern Med 2020; 172:214-215. [PMID: 31905378 DOI: 10.7326/m19-3731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Katy J L Bell
- The University of Sydney, Sydney, New South Wales, Australia (K.J.B.)
| | - Christopher Semsarian
- The University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (C.S.)
| | - Jenny Doust
- Bond University, Gold Coast, Queensland, Australia (J.D.)
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Glasziou PP, Jones MA, Pathirana T, Barratt AL, Bell KJ. Estimating the magnitude of cancer overdiagnosis in Australia. Med J Aust 2019; 212:163-168. [PMID: 31858624 PMCID: PMC7065073 DOI: 10.5694/mja2.50455] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/27/2019] [Indexed: 12/24/2022]
Abstract
Objectives To estimate the proportion of cancer diagnoses in Australia that might reasonably be attributed to overdiagnosis by comparing current and past lifetime risks of cancer. Design, setting, and participants Routinely collected Australian Institute of Health and Welfare national data were analysed to estimate recent (2012) and historical (1982) lifetime risks (adjusted for competing risk of death and changes in risk factors) of diagnoses with five cancers: prostate, breast, renal, thyroid cancers, and melanoma. Main outcome measure Difference in lifetime risks of cancer diagnosis between 1982 and 2012, interpreted as probable overdiagnosis. Results For women, absolute lifetime risk increased by 3.4 percentage points for breast cancer (invasive cancers, 1.7 percentage points), 0.6 percentage point for renal cancer, 1.0 percentage point for thyroid cancer, and 5.1 percentage points for melanoma (invasive melanoma, 0.7 percentage point). An estimated 22% of breast cancers (invasive cancers, 13%), 58% of renal cancers, 73% of thyroid cancers, and 54% of melanomas (invasive melanoma, 15%) were overdiagnosed, or 18% of all cancer diagnoses (8% of invasive cancer diagnoses). For men, absolute lifetime risk increased by 8.2 percentage points for prostate cancer, 0.8 percentage point for renal cancer, 0.4 percentage point for thyroid cancer, and 8.0 percentage points for melanoma (invasive melanoma, 1.5 percentage points). An estimated 42% of prostate cancers, 42% of renal cancers, 73% of thyroid cancers, and 58% of melanomas (invasive melanomas, 22%) were overdiagnosed, or 24% of all cancer diagnoses (16% of invasive cancer diagnoses). Alternative assumptions slightly modified the estimates for overdiagnosis of breast cancer and melanoma. Conclusions About 11 000 cancers in women and 18 000 in men may be overdiagnosed each year. Rates of overdiagnosis need to be reduced and health services should monitor emerging areas of overdiagnosis.
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Affiliation(s)
- Paul P Glasziou
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, QLD
| | | | | | - Katy Jl Bell
- Sydney School of Public Health, University of Sydney, Sydney, NSW
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Kazda L, Bell K, Thomas R, McGeechan K, Barratt A. Evidence of potential overdiagnosis and overtreatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents: protocol for a scoping review. BMJ Open 2019; 9:e032327. [PMID: 31699747 PMCID: PMC6858259 DOI: 10.1136/bmjopen-2019-032327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Worldwide, attention deficit hyperactivity disorder (ADHD) diagnosis rates in children and adolescents have been increasing consistently over the past decades, fuelling a debate about the underlying reasons for this trend. While many hypothesise that a substantial number of these additional cases are overdiagnosed, to date there has been no comprehensive evaluation of evidence for or against this hypothesis. Thus, with this scoping review we aim to synthesise published evidence on the topic in order to investigate whether existing literature is consistent with the occurrence of overdiagnosis and/or overtreatment of ADHD in children and adolescents. METHODS AND ANALYSIS The proposed scoping review will be conducted in the context of a framework of five questions, developed specifically to identify areas in medicine with the potential for overdiagnosis and overtreatment. The review will adhere to the Joanna Briggs Methodology for Scoping Reviews. We will search Medline, Embase, PsycINFO and the Cochrane Library electronic databases for primary studies published in English from 1979 onwards. We will also conduct forward and backward citation searches of included articles. Data from studies that meet our predefined exclusion and inclusion criteria will be charted into a standardised extraction template with results mapped to our predetermined five-question framework in the form of a table and summarised in narrative form. ETHICS AND DISSEMINATION The proposed study is a scoping review of the existing literature and as such does not require ethics approval. We intend to disseminate the results from the scoping review through publication in a peer-reviewed journal and through conference presentations. Further, we will use the findings from our scoping review to inform future research to fill key evidence gaps identified by this review.
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Affiliation(s)
- Luise Kazda
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Katy Bell
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rae Thomas
- Institute of Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Kevin McGeechan
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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O'Keeffe M, Barratt A, Maher C, Zadro J, Fabbri A, Jones M, Moynihan R. Media Coverage of the Benefits and Harms of Testing the Healthy: a protocol for a descriptive study. BMJ Open 2019; 9:e029532. [PMID: 31446410 PMCID: PMC6721653 DOI: 10.1136/bmjopen-2019-029532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Much testing in medicine is aimed at healthy people to facilitate the early detection of health conditions. However, there is growing evidence that early detection is a double-edged sword that may cause harm in the form of overdiagnosis. The media can be seen as a major generator of consumer demand for health services. Previous research shows that media coverage tends to overstate the benefits and downplay the harms of medical interventions for the sick, and often fails to cover relevant conflicts of interest of those promoting those interventions. However, little is known about how the benefits and harms of testing the healthy are covered by media. This study will examine the media coverage of the benefits and harms of testing the healthy, and coverage of potential conflicts of interest of those promoting the testing. METHODS AND ANALYSIS We will examine five tests: 3D mammography for the early detection of breast cancer; blood liquid biopsy for the early detection of cancer; blood biomarker tests for the early detection of dementia; artificial intelligence technology for the early detection of dementia; and the Apple Watch Series 4 electrocardiogram sensor for the early detection of atrial fibrillation. We will identify media coverage using Google News and the LexisNexis and ProQuest electronic databases. Sets of two independent reviewers will conduct story screening and coding. We will include English language media stories referring to any of the five tests from January 2016 to May 2019. We will include media stories if they refer to any benefits or harms of the test for our conditions of interest. Data will be analysed using categorical data analysis and multinomial logistic regression. ETHICS AND DISSEMINATION No ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature.
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Affiliation(s)
- Mary O'Keeffe
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher Maher
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Joshua Zadro
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Alice Fabbri
- Charles Perkins Centre and School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Ray Moynihan
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
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Lord SJ, St John A, Bossuyt PM, Sandberg S, Monaghan PJ, O'Kane M, Cobbaert CM, Röddiger R, Lennartz L, Gelfi C, Horvath AR. Setting clinical performance specifications to develop and evaluate biomarkers for clinical use. Ann Clin Biochem 2019; 56:527-535. [PMID: 30987429 DOI: 10.1177/0004563219842265] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Biomarker discovery studies often claim ‘promising’ findings, motivating further studies and marketing as medical tests. Unfortunately, the patient benefits promised are often inadequately explained to guide further evaluation, and few biomarkers have translated to improved patient care. We present a practical guide for setting minimum clinical performance specifications to strengthen clinical performance study design and interpretation. Methods We developed a step-by-step approach using test evaluation and decision-analytic frameworks and present with illustrative examples. Results We define clinical performance specifications as a set of criteria that quantify the clinical performance a new test must attain to allow better health outcomes than current practice. We classify the proposed patient benefits of a new test into three broad groups and describe how to set minimum clinical performance at the level where the potential harm of false-positive and false-negative results does not outweigh the benefits. (1) For add-on tests proposed to improve disease outcomes by improving detection, define an acceptable trade-off for false-positive versus true-positive results; (2) for triage tests proposed to reduce unnecessary tests and treatment by ruling out disease, define an acceptable risk of false-negatives as a safety threshold; (3) for replacement tests proposed to provide other benefits, or reduce costs, without compromising accuracy, use existing tests to benchmark minimum accuracy levels. Conclusions Researchers can follow these guidelines to focus their study objectives and to define statistical hypotheses and sample size requirements. This way, clinical performance studies will allow conclusions about whether test performance is sufficient for intended use.
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Affiliation(s)
- Sarah J Lord
- 1 School of Medicine, University of Notre Dame, Darlinghurst, New South Wales, Australia.,2 National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - Patrick Mm Bossuyt
- 4 Department of Clinical Epidemiology, Biostatistics & Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sverre Sandberg
- 5 Department of Global Public Health and Primary Health Care, University of Bergen, Norway.,6 The Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway.,7 Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
| | - Phillip J Monaghan
- 8 Department of Clinical Biochemistry, The Christie Pathology Partnership, The Christie NHS Foundation Trust, Manchester, UK
| | - Maurice O'Kane
- 9 Clinical Chemistry Department, Altnagelvin Hospital, Western Health and Social Care Trust, Londonderry, UK
| | - Christa M Cobbaert
- 10 Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Ralf Röddiger
- 9 Clinical Chemistry Department, Altnagelvin Hospital, Western Health and Social Care Trust, Londonderry, UK.,11 Clinical Operations, Global Medical and Scientific Affairs, Roche Diagnostics GmbH, Mannheim, Germany
| | | | - Cecilia Gelfi
- 13 Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Andrea R Horvath
- 14 Department of Clinical Chemistry & Endocrinology, Prince of Wales Hospital, New South Wales Health Pathology and School of Medical Sciences, University of New South Wales, Randwick, Australia.,15 School of Public Health, University of Sydney, Camperdown, Australia
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