Overdiagnosis in primary care: framing the problem and finding solutionsBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2820 (Published 14 August 2018) Cite this as: BMJ 2018;362:k2820
- Minal S Kale, assistant professor1,
- Deborah Korenstein, chief of the general internal medicine service2
- 1Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
- 2Department of Medicine and Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY 10017, USA
- Correspondence to: D Korenstein
Overdiagnosis, is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime, and it is increasingly acknowledged as a consequence of screening for cancer and other conditions. Because preventive care is a crucial component of primary care, which is delivered to the broad population, overdiagnosis in primary care is an important problem from a public health perspective and has far reaching implications. The scope of overdiagnosis as a result of services delivered in primary care is unclear, though overdiagnosis of indolent breast, prostate, thyroid, and lung cancers is well described and overdiagnosis of chronic kidney disease, depression, and attention-deficit/hyperactivity disorder is also recognized. However, overdiagnosis is a known consequence of all screening and can be assumed to occur in many more clinical contexts. Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden. Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions. Efforts to reduce overdiagnosis are hindered by physicians’ and patients’ lack of awareness of the problem and by confusion about terminology, with overdiagnosis often conflated with related concepts. Clarity of terminology would facilitate physicians’ understanding of the problem and the growth in evidence regarding its prevalence and downstream consequences in primary care. It is hoped that international coordination regarding diagnostic standards for disease definitions will also help minimize overdiagnosis in the future.
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Contributors: MSK and DK substantially contributed to the conception, analysis, data interpretation, manuscript drafting, and critical revision of this article. Both authors gave final approval of this version of the manuscript for publication. Both authors agree to be accountable for all aspects of the work to ensure that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved.
Funding: This study was not funded. MSK is funded by a career development award (K07CA187071) from the National Cancer Institute of the National Institutes of Health. DK’s work on this project was supported in part by a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center (P30 CA0087848). MSK’s work was supported in part by an NIH grant (NCI K07CA187071).
Competing interests: The authors have read and understood BMJ policy on declaration of interests and declare that we have no interests.
Provenance and peer review: Commissioned; externally peer reviewed.