Eric Coon, Ricardo Quinonez, Alan Schroeder
One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of over-diagnosis in pediatric HM and its contribution to patient harm. The first key point is the distinction between over-diagnosis and mis-diagnosis. Over-diagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from mis-diagnosis or incorrect diagnosis. Over-diagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and increasing use of screening tests.
The speakers outlined many, varied drivers of over-diagnosis, including physicians’ unawareness of over-diagnosis, physicians’ discomfort with uncertainty, system incentives such as fee for service which reimburses or rewards increased testing, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and physicians’ inherent belief in technology and its results.
The classic example of over-diagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing, an increase in diagnosis, but no change in mortality. A current example is children receiving head CT scans for minor head trauma that can lead to a diagnosis of small asymptomatic head bleeds or non-displaced skull fractures, which can then lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.
From the patient perspective, over-diagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary being given a label of a diagnosis or disease.
The bottom line for physicians to consider when ordering a test is not just does the patient benefit from detection or diagnosis, but also what is the potential harm?
James O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.