Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2035 (Published 22 May 2018) Cite this as: BMJ 2018;361:k2035
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I share Dr Llewelyn’s frustration that the views expressed in this essay do not offer us any clear way forward. Like many others [1, 2], Woloshin and Schwartz clearly recognise the complexity of factors affecting decisions and preferences about health care choices, listing a multitude of potentially important influences driving variation, including everything from commercial influences to the availability of services, as well as the professional and wider cultural factors that are likely to be in play.[3]
More research documenting and assessing the harms of ‘too much medicine’ is welcome and necessary, as is the proposed integration of patient preferences into decision making processes. However, given the complexity of the problem, it is unlikely that EBM and SDM alone can save us. Proposed reforms must take into account factors including the realities of prevailing attitudes to risk, the uncertainty (and controversy) in the existing evidence base and existing practices and structures in our health care systems. Lisa Rosenbaum is right to suggest that “understanding *why* we deliver unnecessary care deserves scientific enquiry” (my emphasis) [4]. Without developing our understanding of how important contextual factors interact to affect doctors’ and patients’ attitudes, preferences and reasoning, we are unlikely to be able to address the resulting variation in care.
1. Pathirana, T, Clark, J, Moynihan, R. Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017;358:j3879. https://doi.org/10.1136/bmj.j3879
2. Hofmann, B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol 2014;29;9:599-604. https://link.springer.com/article/10.1007%2Fs10654-014-9920-5
3. Woloshin S, Schwartz LM. Overcoming overuse: the way forward is not standing still. BMJ 2018;361:k2035. https://doi.org/10.1136/bmj.k2035
4. Rosenbaum L. The less-is-more crusade—are we overmedicalizing or oversimplifying? N Engl J Med2017;377:2392-7. . https://doi.org/10.1056/NEJMms1713248
Competing interests: No competing interests
Dr Llewellyn makes the point that inadequate statistical methods have led to the misinterpretation of research findings. This, in turn, has led to the problem of overdiagnosis and overprescription. However, I would argue that it is not the RCT itself that is the problem, but the way that this has been implemented. Do not forget that it was the "gold standard" of research that led to the discovery of the link between Vitamin C and scurvy in the 18th Century [1]. Years later, a series of clinical trials [e.g. 2] found a link between retrolental fibroplasia (blindness in infants) and oxygen therapy. However, this finding was delayed for several years by nurses failing to adhere to trial protocol, i.e. administering oxygen to the control group, rather than the intervention group [3].
I would personally suggest that it is human error that is responsible for overtreatment, rather than statistical anomaly.
[1] Lind, J., 1757. A treatise on the scurvy: in three parts, containing an inquiry into the nature, causes, and cure, of that disease. A. Millar.
[2] Jonathan T. Lanman, M.D.; Loren P. Guy, M.D.; Joseph Dancis, M.D. 1954 RETROLENTAL FIBROPLASIA AND OXYGEN THERAPY JAMA. 1954;155(3):223-226. doi:10.1001/jama.1954.03690210001001 https://jamanetwork.com/journals/jama/article-abstract/317251
[3] Torgerson, D., 2008. Designing randomised trials in health, education and the social sciences: an introduction. Springer.
Competing interests: No competing interests
The views expressed here in the BMJ [1] and in the NEJM [2] do not offer a clear way forward. Experienced doctors have always been aware of the trade-off between over-diagnosis and under-diagnosis, over-treatment and under-treatment. The eternal problem is ‘too much uncertainty’ when trying to predict outcomes with and without interventions. It is clearly important to share decisions with patients, but that will not reduce the degree of uncertainty for predictions either. We need a more sophisticated understanding of the diagnostic and prognostic processes and better directed research.
EBM currently assesses tests and their results by their ability to predict ‘gold standard’ diagnostic test results. The latter are also used to recruit patients for RCTs. The problem is that these ‘gold standards’ are adopted without any real supporting evidence for their predictive value, so it is not surprising that there is over-diagnosis and related problems. Assuming constant relative risk reduction and extrapolating of risk over time additively also undermine the interpretation of RCTs as they only provide approximations for low probabilities found in epidemiology. Bayes simple rule with specificity and likelihood ratios is also an inadequate model of diagnostic reasoning [3,4,5].
There will have to be a more sophisticated approach to the problem and better directed research if there is to be progress.
References
1. Woloshin S, Schwartz LM. Overcoming overuse: the way forward is not standing still. BMJ 2018;361:k2035
2. NEJM Rosenbaum L. The less-is-more crusade—are we overmedicalizing or oversimplifying? N Engl J Med2017;377:2392-7. . doi:10.1056/NEJMms1713248 pmid:29236644
3. Llewelyn H, Ang AH, Lewis K, Abdullah A. The Oxford handbook of clinical diagnosis;.3rd ed. Oxford University Press, 2014: 615-64. http://oxfordmedicine.com/view/10.1093/med/9780199679867.001.0001/med-97...
4. Llewelyn H. The way forward from “rubbish” to “real” EBM in the wake of Evidence Live 2015. http://blogs.bmj.com/bmj/2015/04/28/huw-llewelyn-the-way-forward-from-ru...
5. Llewelyn, H. Sensitivity and specificity are not appropriate for diagnostic reasoning. BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4071. https://www.bmj.com/content/358/bmj.j4071
Competing interests: No competing interests
Re: Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz
Woloshin and Schwartz, alongside other Less Is More Crusaders, place great faith in sharing decisions as a way forward in the fight against overdiagnosis.(1) I consider myself a Less Is More Crusader, but I am slightly less optimistic about the potential of shared decision making to fix this complex problem. The process of providing unbiased information about benefits and harms and aligning health decisions with preferences and values, is clearly preferable in some clinical contexts. The decision to undergo breast cancer screening, for example, where women must weigh the likelihood of avoiding early death with the likelihood of overdiagnosis, lends itself to shared decision-making and the philosophy of informed choice. In other clinical contexts, where the benefit/harm trade-off clearly indicates net harm, this approach may be less valuable. Imaging of non-serious low back pain, for example, is a test that offers patients no benefits but substantial harms from overdiagnosis and overtreatment.(2) It is discouraged by all clinical guidelines. Should clinicians be spending time sharing decisions about having this test or should it be off the table altogether? While I agree with Dr Duddy in her response—we should continue investigating key drivers of overtesting and overtreatment—this will be slow. We need action now. A promising way forward would be to conduct more high-quality trials of strategies to stop clinicians providing tests that are clearly useless and harmful.
Woloshin and Schwartz also raise an important ethical conundrum for those charged with preventing overdiagnosis. The authors state emphatically: “Hype is hype, whether for more or for less care.” In other words, any use of hype or exaggeration of findings—rather than providing balanced information—to promote one’s agenda, never leads to good things. I disagree with this conclusion. My question to the authors is: if our goal is to change behaviour (e.g. encourage conversations between patients and doctors about harms of overtesting, discourage clinicians ordering tests by default etc.) how might we do this without some hype, persuasion, or at least a nudge, in the ‘right’ direction?(3) The authors acknowledge that the numbers are usually uncertain. Will it be enough to—taking the informed choice/shared understanding approach—inform the public of the magnitude of benefit (which we are uncertain about) and compare it to the magnitude harms from overdiagnosis (which we are uncertain about)? It is also worth noting that the Less is More movement is the underdog here; up against a culture where deep-seated beliefs that more-is-better dominate in healthcare and in popular media, and where powerful companies and individuals profit substantially from providing more rather than less.(4) Is it unethical, then, to use hype, persuasion, or hyperbole to level the playing field, especially if that hype could ultimately improve health? One of the recommended strategies to tackle cultural drivers of overuse is a public awareness campaign.(4) Should designers of these campaigns draw the line at promoting informed choice? Or should they consider approaches that can change behaviour and reduce harm, but that risk undermining public trust?
1. Woloshin S, Schwartz LM. Overcoming overuse: the way forward is not standing still-an essay by Steven Woloshin and Lisa M Schwartz. BMJ. 2018;361:k2035.
2. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018. doi: 10.1016/S0140-6736(18)30480-X. [Epub ahead of print]
3. Scott IA, Soon J, Elshaug AG, Lindner R. Countering cognitive biases in minimising low value care. Med J Aust. 2017;206(9):407-11.
4. Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ. 2017;358:j3879.
Competing interests: No competing interests