Thursday, May 31, 2012
All's Not Quiet on the Less-is-more Front
Coming next year -- yes, the wheels of science grind slow, but they grind fine -- the Preventing Overdiagnosis Conference. Overdiagnosis means that people who have some condition that will never harm them get a disease label and, almost inevitably, treatment. Said treatment is at the very least costly, quite likely harmful, and the person must live with an unsettling and possibly even stigmatizing consciousness of being sick, or "at risk."
Overdiagnosis comes from screening that can't discriminate well between dangerous and harmless lesions. Examples are mammography for breast cancer, and PSA for prostate cancer. Those have been much belabored here. It also happens when the threshold for declaring that a "disease" exists is set too low, so that on average the costs of treatment outweigh the benefits. We may have done this with high blood pressure, diabetes, and kidney disease. And it happens when we define diseases that may not even exist, or for which the cure right now is worse than the disease. I'm tempted to put Attention Deficit-Hyperactivity Disorder in that category, and probably pediatric bipolar disorder. That would be a controversial position but I'm not alone.
The fact is that the incidence of cancer has been rising for decades, but the death rate has not fallen much. That is pretty much prima facie proof of overdiagnosis. Lots of old folks are put on dialysis who really don't need it, and they actually die sooner than people who are not. (Renal function declines as we get older, but the rate of decline is much slower than it is in people who really have kidney disease.)
Many people have been found to be using inhaled corticosteroids, for asthma, and antidepressants, who do not actually meet diagnostic criteria for those diseases. I'm not sure whether "overdiagnosis" is the right word in these instances, because they often don't even have a diagnosis in their medical record. They just have a prescription.
Now here's the thing. This is wasting something like 20-30% of all the money spent on health care in this country. Money that could be spent providing access to actually needed health care for people who don't have it. But when we try to do something about it, we get mobs screaming about death panels and pointy headed bureaucrats coming between us and our doctors. We need to ignore those people, and fix this problem.