Survey of public definitions of the term ‘overdiagnosis’ in the UK

Ghanouni, A. et al. BMJ Open. 2016;6:e010723

Objectives: To determine how ‘overdiagnosis’ is currently conceptualised among adults in the UK in light of previous research, which has found that the term is difficult for the public to understand and awareness is low. This study aimed to add to current debates on healthcare in which overdiagnosis is a prominent issue.

Design: An observational, web-based survey was administered by a survey company.

Setting: Participants completed the survey at a time and location of their choosing.

Participants: 390 consenting UK adults aged 50–70 years. Quota sampling was used to achieve approximately equal numbers in three categories of education and equal numbers of men and women.

Primary outcome measures: Participants were asked whether they had seen or heard the term ‘overdiagnosis’. If they had, they were then invited to explain in a free-text field what they understood it to mean. If they had not previously encountered it, they were invited to say what they thought it meant. Responses were coded and interpreted using content analysis and descriptive statistics.

Results: Data from 390 participants were analysed. Almost a third (30.0%) of participants reported having previously encountered the term. However, their responses often indicated that they had no knowledge of its meaning. The most prevalent theme consisted of responses related to the diagnosis itself. Subthemes indicated common misconceptions, including an ‘overly negative or complicated diagnosis’, ‘false-positive diagnosis’ or ‘misdiagnosis’. Other recurring themes consisted of responses related to testing (ie, ‘too many tests’), treatment (eg, ‘overtreatment’) and patient psychology (eg, ‘overthinking’). Responses categorised as consistent with ‘overdiagnosis’ (defined as detection of a disease that would not cause symptoms or death) were notably rare (n=10; 2.6%).

Conclusions: Consistent with previous research, public awareness of ‘overdiagnosis’ in the UK is low and its meaning is often misunderstood or misinterpreted.

Read the full article here

Culture, evidence and implementation // BMJ Clinical Evidence Blog

Cave, J.A.H. BMJ Clinical Evidence Blog. Published online: 7th April  2016.

Over two decades ago I joined a practice in the rolling Berkshire Downs. As a young thrusting, straight-out-of-VTS GP I was keen to do a new activity called “an audit”. This was a completely new thing to my partners and it took some explaining to them why it might be useful. “But I always check the electrolytes on my patients on an ACEI “ the senior partner replied when I suggested we could audit this, “you’ll just be wasting your time”.

In 1990 70% of our prescribing was by branded drugs so I set to in switching the practice to generics. Remarkably we were prescribing thyroxine by the brand Eltroxin at that time, so this seemed a good place to start. I wrote a letter and placed a photocopy of it with every prescription we sent out. Well that was simple and effective I thought, and I have saved the NHS £1000s. I had, however, not counted on the village of Hampstead Norreys. Reports came in of the new drug causing headaches, abdominal problems, rashes and we even had one report that the new drug didn’t taste right. By the end of the month we have several dozen people back on their Eltroxin.

These stories highlight the importance not just of good evidence and communication but of the importance of culture. As a GP we cannot work outside the culture of our patients, indeed GPs would not be good GPs if they tried. Yet those developing policy and creating guidance sometimes forget this. More recent examples of culture eating evidence for breakfast include the use of statins in primary prevention. It can be difficult to get patients interested in taking a statin when they have a 10% risk of a cardiovascular event because most imagined their risk was much higher to begin with. I only have a 10% chance of having a heart attack! This is great news, why would I want a statin!

Read the full blog here

Digital requirements for new primary care models

This briefing from the Nuffield Trust looks at emerging changes in primary care, and how digital technology can help managers and clinicians to deliver them.

General practice faces historic demands and pressures: tight funding, a medical workforce shortage, more complex patients and the demand for seven day access.

This briefing examines how technology can underpin a series of changes enabling primary care to meet these challenges. The report looks towards a possible future in which general practice operates at scale; functions as one with other organisations; and delivers care through a diverse range of professionals.

Drawing on six case study sites using new technologies, the report shows how innovations such as shared health records, patient portals for booking, remote consultation and telehealth are supporting these changes. Finally, the local and national barriers to realising this vision are highlighted, with discussion as to how they can be overcome.

More HOPE for Prevention with Statins

Cushmann, W.C. & Goff, D.C. New England Medical Journal. Published online: April 2, 2016

In view of the worldwide burden of cardiovascular disease and the high cost of and poor adherence to medication regimens for the prevention of cardiovascular disease, the concept of a “polypill” — a single pill that combines several medications — is an attractive public health approach. However, evidence that each component of a polypill would independently reduce the risk of cardiovascular events and that the combination of agents would be safe is lacking.

The primary results of the Heart Outcomes Prevention Evaluation (HOPE)–3 trial are now reported in three articles in the Journal.HOPE-3 was a double-blind, randomized, placebo-controlled trial with a 2-by-2 factorial design, in which 12,705 intermediate-risk men (≥55 years of age) and women (≥60 years of age) who did not have cardiovascular disease were randomly assigned to receive cholesterol-lowering treatment with rosuvastatin at a dose of 10 mg per day or placebo and were also randomly assigned to receive blood-pressure–lowering treatment with candesartan at a dose of 16 mg per day plus hydrochlorothiazide at a dose of 12.5 mg per day or placebo for a median of 5.6 years. Treatment with rosuvastatin resulted in a 24% lower risk of cardiovascular events than that with placebo (absolute difference, 1.1 percentage points), but the antihypertensive therapy did not result in a significantly lower risk of cardiovascular events.

The HOPE-3 trial provides evidence to reinforce some current guideline recommendations and to influence future guidelines.

Read the full article here