October 26, 2011

DEFINING NORMAL DOWNWARDS:

Overdiagnosis: Bad for You, Good for Business (Lisa Chedekel, 10/26/11, BU Today)

After the criteria used to define osteoporosis were expanded in 2003, seven million American women were turned into patients virtually overnight. Diagnoses of high blood pressure, diabetes, and cancer also have skyrocketed over the past few decades--yet the number of deaths from those diseases has been largely unaffected.

While conventional wisdom holds that early diagnosis is good, H. Gilbert Welch, a professor of medicine and director of the Center for Medicine and the Media at the Dartmouth Institute for Health Policy and Clinical Practice, views it as a major problem for modern medicine, with myriad social, medical, and economic implications. In his new book, Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 2011), Welch and coauthors Lisa Schwartz and Steven Woloshin write about the hazards of looking too hard for illnesses in healthy people, including additional procedures that carry no benefit, but may cause harm, higher health care costs, and psychological detriments. [...]


You've talked about health conditions defined by numbers, or benchmarks--like high blood pressure, high cholesterol, diabetes, and osteoporosis--numbers that distinguish between who's healthy and who's sick. Aren't those numbers based on sound science?

Yes--and no. Yes, in that we know these conditions can be important and that treatment can help--i.e., treating really high blood pressure is one of the most important things we doctors do. But no, in that the "rule" by which health conditions are gauged--the number which, if you are on one side of it, you are well, but if you are on the other side of it, you are sick--has been regularly changing. For example, a fasting blood sugar of 130 was not considered to be diabetes before 1997, but now it is. And these numbers are always changing in one direction: the direction of labeling more and more people as abnormal.

The problem is that these newly created patients stand to benefit the least from intervention. Yet they face roughly the same amount of harm from intervention. In other words, the net effect of intervention may be harm. For example, as we recently learned in diabetes, while trying to move people with mildly elevated blood sugars towards "normal," the death rate increased.

The generic problem is one of balance. Doctors tend to focus on those we might conceivably help, even if it's only one out of 100 (the benefit of lowering cholesterol in those with normal cholesterol but elevated C-reactive protein) or one out of 1,000 (the benefit of breast and prostate cancer screening).

We believe this is what our patients, and the public, care about. But it's time for everyone to start caring about what happens to the other 999.

Who benefits from overdiagnosis?

A lot of people: pharma, device manufacturers, imaging centers, and even your local hospital. The easiest way to make money isn't to build a better drug or device--it's to expand the market for existing drugs and devices by expanding the indication to include more patients. Similarly, for hospitals, the easiest way to make money isn't to deliver better care; it's to recruit new patients--and screening is a great way to do this.


Posted by at October 26, 2011 6:46 AM
  

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