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Over-diagnosis, over-treatment & over-screening Over-diagnosis, over-treatment & over-screening

Over-diagnosis, over-treatment & over-screening - PowerPoint Presentation

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Over-diagnosis, over-treatment & over-screening - PPT Presentation

Robin W Paton PhD FRCS FRCS Orthopaedic BOTA 2015 What is overdiagnosis First do no harm Disease A disorder of structure or function that is not simply a direct result of physical injury ID: 219230

screening amp diagnosis treatment amp screening treatment diagnosis orthopaedics clinical 2014 evidence medicine fractures specificity sensitivity vitamin surgery scoliosis

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Slide1

Over-diagnosis, over-treatment & over-screening

Robin W Paton PhD FRCS FRCS (Orthopaedic)BOTA 2015Slide2

What is over-diagnosis?

First do no harm!Disease: A disorder of structure or function that is not simply a direct result of physical injury! Oxford dictionary

Over-diagnosis: Asymptomatic individuals are diagnosed with a disease that will not cause them to experience symptoms or an early deathSlide3

What is over-diagnosis? First do no harm

! Patients deserve accurate diagnosis & appropriate treatment

Over-diagnosis of the wellUnder-treatment of the sick‘Conjoint twins of modern medicine’ Heath 2014Slide4

Drivers of over diagnosis

‘Ability to detect smaller abnormalities axiomatically tend to increase the prevalence of any given disease’ Black 1998Faith in early detection unmodified by risks

Legal incentives that punish under diagnosis but not over diagnosisTechnological changes detecting ever smaller ‘abnormalities’Commercial

and professional interests BMJ 2 June 2012 Slide5

Role of fear in over-diagnosis

BMJ 8 November 2014Patients need clinicians that reassert the border between the well & the sickThe risk of missing a diagnosis frightens Doctors: ‘naming & shaming’/ public pilloryingProtocols, guidelines & ‘screening’ leads to over-diagnosis & over-treatment

Heath 2014Slide6

Self perpetuating loop of diagnostics:Disease mongering & Over-medicalisation

New test Increased accuracyDiagnosis of mild disease/ pseudo disease (spectrum shift)

Treatment results improved outcomes/ ‘success’ Hofmann BMJ 2015 Moynihan et al 2012Slide7

Algorithm based medicine

Dreyfus model of learningNovice: learns basic rules & applies mechanically with no attention to context

(level one): MechanicalExpert: rapid, intuitive reasoning informed on imagination, common sense, selected research & other evidence (level five): Judgement

 

Expert

Proficient

Competent

Advanced Beginner

Novice

Intuition

Experience

Involved

‘Rules’

Analytic

Detached

 Slide8

The role of evidence based medicine (EBM)

Problems: Algorithms have replaced patient centred care Statistical significance = to clinical benefits?

EBM guidelines struggle to contend with multiple morbidities Volume & source of evidence (NICE) Industry & Government interference / bias

Greenhalgh 2014 Slide9

The role of evidence based medicine (EBM) &

Expert Consensus Based medicine (ECBM)Prior to EBM: anecdote, theoretical reasoning from basic science (Dreyfus expert?) Risk of conclusions being accepted without critical review:

Eminence based medicine!EBM: evidence from high quality RCTs & observational studies in combination with clinical expertise‘ECBM’ :

the way forward or fudge? individual evidence & shared decisions i.e. NICE Greenhalgh

2014

Stirling 2014Slide10

Choosing Wisely R , ‘Less is more’ & ‘Too much medicine’

Orthopaedics (USA & Canada): Lack of ambition? Avoid routine post-operative DVT ultrasonography screening in elective TKR & THR

Avoid needle lavage in symptomatic OA of the knee for long term reliefAvoid glucosamine & chondroitin in the treatment of symptomatic OA (knee)Avoid lateral wedge insoles in patients with symptomatic medial compartment OA (knee)Avoid post-operative splinting of the wrist after carpal tunnel release for long term reliefSlide11

‘Less is more’: Canada

Canadian health care system: Dominated by hospitals & specialist doctors Not compensated to recommend alternatives to medical treatment i.e. physiotherapy not covered by medicare

: = operation cheaper?Scandinavian health care system: focus on preventive medicine & primary careSlide12

Can we do more?Surgical procedures

Arthroscopic washout of advanced OA of the knee Arthroscopic debridement of degenerative meniscal tears Arthroscopic shoulder procedures: NICE 2007,

RCT sham surgery, Moseley 2002 BJJ 96-B, 2014, editorial BJSM, 2015Mid shaft clavicle fractures (ORIF): 24.6% repeat surgery Leroux

2014Childrens’ distal radial fractures: > 90% should be treated conservativelyLocking plates in adult distal radial fractures?Slide13

Can we do more?

Abandonment of Orthotics in Paediatric OrthopaedicsInsoles in treatment of asymptomatic flat feetOrthotics for physiological intoeing &

strapping for curly toesBracing for physiological genu varum and valgumSlide14

Screening in OrthopaedicsSlide15

Screening in Orthopaedics

Ideal screening programme:Condition must be importantEffective & accepted treatmentTreatment & diagnostic facilities availableRecognisable latent & early symptomatic stageOpinions on who should be treated agreed

Guaranteed safety, sensitivity & specificityExamination & treatment acceptable Natural history knownTests inexpensive & simpleCost effectiveAudited Wilson & Jungner 1968Slide16

Screening in Orthopaedics

Clinical & ultra-sonographic hip screening in DDHScoliosis screeningMRSA pre-operative screeningVitamin D deficiencySlide17

Screening in Orthopaedics

Screening in DDH: ClinicalSurveillance not screeningStatistics: neonatal screening

Clinical sensitivity: 66%Clinical specificity: 99.77%

Clinical PPV: 27.97%U/S sensitivity: 72.1%U/S specificity: 99.0%U/S PPV: 67.8%

Slide18

Screening in OrthopaedicsScreening in DDH: Clinical

Surveillance not screeningStatistics: GP 6 – 8 week (clinical)

Sensitivity: 13.34%Specificity: >99.9%PPV: 4.65%Slide19

Screening in OrthopaedicsScreening in DDH:

‘At Risk’Surveillance not screeningStatistics: ultra-sound ‘at risk’

Sensitivity: 100%Specificity: 94.2% (93.3%)PPV: 20.5% (7.0%)Statistically high sensitivity & specificity (accuracy) combined with a low prevalence can result in a low PPVSlide20

Screening in Orthopaedics

Scoliosis (National screening Committee 2010): Adolescent idiopathic typeScreening asymptomatic adolescents did not detect important degrees of idiopathic scoliosis earlier (than without screening)Most cases detected through screening will not progress to a clinically important form of scoliosis

Scoliosis requiring aggressive treatment (surgery) likely to be detected without screeningEffects of diagnosing scoliosis: potential harmSlide21

Screening in Orthopaedics

MRSA Pre-operative screening (East Lancashire, UK):8,867 patients elective & emergency T & O surgery (2010)Incidence: 0.47% (42)WHO screening criteria: 4 out of 9

33/42 decolonisation therapy, 18 successfullyNo surgical site infection Barkatali et al 2013 Slide22

Screening in Orthopaedics

Vitamin D deficiency (East Lancashire, UK):88% below normal Vitamin D threshold (winter/spring levels statistically lower) Low levels Vitamin D rarely associated with biochemical or radiological rickets (2.61

% with radiological rickets) Foley et al 2012Vitamin D thresholds and radiological rickets Vitamin D < 20mcg/l Vitamin D < 10mcg/lSensitivity (%)

100 66.7Specificity (%) 34.8 76.8PPV (%) 4.0 7.2 Slide23

Under-diagnosis in Orthopaedics

SUFESLESlide24

Summary

Avoid over-diagnosis & over treatment (Dreyfus 5, higher order thinking)Do not classify ‘healthy’ individuals as ‘sick’!

(‘First do no harm’)‘Control’ screening, surveillance is not screeningProduce high quality evidence or be dictated to!Slide25

Thank youSlide26

Can we do more?

Surgical proceduresVertebroplasty vs. sham surgery for pain in vertebral compression fractures Buchbinder

2009, Kallmes 2009Early anterior cruciate reconstruction in young individuals

structured training programme vs. early / delayed optional reconstruction 31% of delayed group ACL reconstruction, 61% no surgery no differences in function at 2 years Frobell

2010

Slide27

Role of classifications in Orthopaedics:Validation?

Useful: Salter- Harris (Childrens’ fractures) Vancouver (periprosthetic #s) Gartland

(supracondylar Humerus) Gustilo & Anderson (tibial fractures)Over-complicated:

Frykman (wrist fractures) Acromio-clavicular joint (Type I to VI) A/O fracture classification

Questionable:

Mangled extremity severity score (MESS)

Milch

(Lateral condylar mass #) Slide28

The role of evidence based medicine (EBM)

Achievements: Cochrane collaboration Higher standards of primary & secondary research

National & International clinical practice guidelines Teaching & development of critical appraisal

Building of knowledge baseSlide29