In the article below, Dr Ray Moynihan explores some of the reasons why tackling the complex problem of too much medicine remains a big priority in the COVID era.
This article is published as part of the TOO MUCH of a Good Thing series, which is investigating how to reduce overdiagnosis and overtreatment in Australia and globally, and is published as a collaboration between Wiser Healthcare and Croakey.
To follow the series, bookmark this link, and follow #WiserHealthcare on Twitter.
Ray Moynihan writes:
A couple of weeks back, in the midst of the global pandemonium, there was one particularly surreal moment. A colleague had emailed me about a new opportunity to apply for research funding.
Nothing out of the ordinary there. As an academic researcher, those opportunities are my bread and butter, and they always generate great interest. This call for research proposals though turned out to be truly extraordinary.
While thousands were dying, health systems were flailing and economies folding, Britain’s biggest medical research funding body had released a new call for research titled “reducing overtreatment.”
More specifically the National Institutes for Health Research was calling for proposals to study “the evaluation of strategies and interventions to identify and de-intensify overtreatment.”
An initial reaction
As someone deeply engaged for a long time with the problem of too much medicine, my initial reaction was unexpected. The call for research on overtreatment somehow felt wrong. It seemed like a disrespectful distraction from the urgent need to respond to the pandemic.
Surely this was not the time to be worrying about medical excess. Perhaps anticipating reactions like mine, the funding body had a strong disclaimer up-front.
It stressed that COVID-19 research “should always be the priority” at this time. But then went on to explain that the new call was part of a wider plan “to keep the future research pipeline healthy.”
On further reflection there are of course very strong reasons to continue to investigate and tackle medical excess. Much has changed in recent months.
Yet as with the climate crisis, the facts about too much medicine remain the same. There are reliable estimates, from the United States and from the OECD, that around one in five dollars spent on healthcare is wasted, including on unnecessary tests, diagnoses and treatments.
The problem with overdiagnosis
A key driver of the problem of too much medicine is overdiagnosis, which happens when people receive an unnecessary diagnosis, defined as a diagnosis that will cause them more harm than good.
New Australian research from early 2020 estimates a whopping one in five major cancers may be overdiagnosed cancers.
In other words, those cancers would not have gone on to cause the person diagnosed any harm if they were left undetected. According to that paper – published in the Medical Journal of Australia – around 29 000 Australians may be overdiagnosed with these cancers every year.
Most of them will also be treated unnecessarily, so they will suffer untold harms from the anxiety of a frightening label, as well as the complications of invasive tests and treatments.
The epidemic of unnecessary care
Just last month, as the COVID lock downs took hold in many places, authors of an article in the New England Journal of Medicine reminded us of the epidemic of unnecessary care caused by screening healthy men for prostate cancer, using the PSA test.
“PSA screening represents a textbook case of overdiagnosis and overtreatment in medical care” they wrote.
As they explained, in recent decades in the United States, alongside the many men who have benefited from a screening test picking up a deadly cancer early, “more than a million men were diagnosed with a clinically insignificant ‘cancer’ and received treatment for pathologic findings not destined to cause symptoms or death.”
Alongside the incalculable harm to individuals there is also the massive costs of this problem to health systems. Yet to be calculated in Australia, one estimate from the United States suggested the overdiagnosis of breast cancer alone was costing that nation US$1.2 billion a year.
If you add in the costs from false positives from breast cancer screening, the figure is US $4 billion annually.
And apart from the harm to individuals and costs to health systems, too much medicine is also clearly contributing to excess greenhouse gases, helping to fuel the climate crisis.
Determining harms and costs
There are strong indications that overdiagnosis and overtreatment occurs across many conditions, way beyond cancers. One of the world’s oldest and most prestigious medical journals, The BMJ, is running an on-going campaign to tackle Too Much Medicine.
The campaign has a focus on raising awareness about the problem of overdiagnosis, across a wide range of conditions, from ADHD to gestational diabetes, from osteoporosis to polycystic ovary syndrome.
Often overdiagnosis occurs because definitions of disease have been expanded so much that many healthy people are labelled as sick.
Determining the extent of harms and costs from the overdiagnosis of cancer, and non-cancer conditions, remains a major research question, which will take years to properly answer.
Perhaps more importantly, we also need research to determine the best strategies to wind back all this harmful excess and try to redirect the wasted resources to genuine unmet need.
Thanks in large part to several research grants from the National Health and Medical Research Council, Australia is now at the forefront of research on overdiagnosis internationally.
It was Australia which initiated a new global scientific conference on overdiagnosis, which has become the key forum for discussing the science of the problem and its solutions.
The 8th Preventing Overdiagnosis conference is scheduled to go ahead at Oxford University in September this year, with a special theme on healthcare post-COVID.
A win-win situation
A lack of effective treatments is obviously a huge and on-going challenge in managing COVID-19 right now. But it’s already clear that medical excess is simultaneously a concern, when poorly evaluated, ineffective or dangerous treatments are widely promoted.
More profoundly, as the world seeks ways to fund the extraordinary costs of responding to the pandemic, tackling medical excess may offer a win-win-win situation.
Effectively reducing overdiagnosis and overuse can decrease harm to people, save money for health systems, and wind back healthcare’s contribution to the climate crisis.
Britain’s special call for research on how to reduce overtreatment is perhaps more relevant now than ever.
Dr Ray Moynihan is an Assistant Professor at Bond University’s Institute for Evidence-Based Healthcare, and an NHMRC Early Career Fellow researching overdiagnosis. As a journalist and author, he has published 4 books on the business of medicine.
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