Friday, May 18, 2018

Overdiagnosis, e.g., head trauma

In pediatric medicine, unnecessary testing can be eliminated without compromising outcomes if every physician simply asks how the test will benefit the patient, new data show.

Overtesting and overdiagnosis is prevalent in pediatrics, said Eric Coon, MD, from the University of Utah School of Medicine Primary Children's Hospital in Salt Lake City.

And the increasing incidence of disease might be directly related to overdiagnosis, he said during a special session here at the Pediatric Academic Societies 2018 Meeting.

An increase in the incidence of a disease without any change in morbidity or mortality from that disease is a sign that the abnormalities being detected are not that severe because they are not affecting patient outcomes, he explained. 

For example, Kawasaki disease has long been treated with intravenous immunoglobulin to prevent the development of coronary artery abnormalities that can progress to adverse outcomes, such as thrombosis….

Overdiagnosis can also happen when a child with isolated head trauma presents to the emergency department.

Head Trauma

The physician must decide whether or not the child should undergo a CT scan "to find a fracture or bleed, particularly a slow bleed that, if missed, could extend to catastrophic consequences," Coon explained. 

But the use of CT scans has been on the decline because of concerns that radiation overexposure can contribute to malignancies.

So Coon and his colleagues examined whether the decrease in CT scans was accompanied by a decrease in the detection of abnormalities and, if so, whether patient outcomes were affected.

The team assessed the records of 300,000 children treated for isolated head trauma at 34 children's hospitals in the United States from 2003 to 2015. The use of imaging, including CT scans, peaked at about 40% in 2008, but declined to 25% in 2015.

The incidence of skull fractures and bleeds both declined during the study period, especially after 2008. These declines were accompanied by a decrease in hospitalization rates and neurosurgery, again largely after 2008.

Rates of revisits to the hospital in the week after the index event were exceedingly low during the study period. And mortality and persistent neurologic impairment were very rare outcomes in these children.

"In other words, decreased imaging was accompanied by decreased detection of abnormalities and decreased intervention without measurable harm to the patient," Coon reported. 

Although the use of bicycle helmets — and perhaps seatbelts and even the heightened awareness of concussion — could explain why children with less-severe head injuries were seen over time in the emergency department, "the trends we found were consistent across age groups, so increased use of bike helmets should not affect children under the age of 2 years," Coon observed.

"The implication here is that we can safely do less while decreasing radiation exposure and reduce overdiagnosis," he concluded…

Changing the mindset of residents in training might be a good place to start to reverse the drive to overtest and overtreat.

Residents are often asked to go through a diagnostic-dilemma exercise, in which they are presented with the most esoteric, most random, most fascinating disease their mentors can come up with, Schroeder explained.

"We go around the room and create this tremendous list of diseases that many of us have never seen before, and then the laundry list of tests starts. We don't give a lot of thought about how that test will help patients," he said.

Teachers should move away from asking what the patient has, he suggested, and simply ask, "How can the test help this particular patient?"

Many think that an evidence-based approach to testing is to ask whether test results will change management, "but I don't think that is the right question," Schroeder said. "We've shown that test results can change management without benefiting patients."

"The right question is, 'How will this test provide net benefit to my patient?'" he pointed out. "This is one way to mitigate some of our concerns about overdiagnosis."…

"We also have to critically evaluate standard practice," such as the practice of prescribing long courses of antibiotics when much shorter courses will do, she added.

We are taught to first do no harm, be we actually think, "first do something," Moyer said. "We have to learn to be comfortable with uncertainty, focus more on value and less on cost, and address clinician fears about underuse."

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