Intended for healthcare professionals

Opinion

Overdiagnosis and too much medicine in a world of crises

BMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p1865 (Published 12 August 2023) Cite this as: BMJ 2023;382:p1865
  1. Thomas Kühlein1,
  2. Helen Macdonald2,
  3. Barnett Kramer3,
  4. Minna Johansson4,
  5. Steven Woloshin45,
  6. Kirsten McCaffery6,
  7. John B. Brodersen7,
  8. Tessa Copp8,
  9. Karsten Juhl Jørgensen9,
  10. Anne Møller10,
  11. Martin Scherer11
  12. for the Scientific Committee of the Preventing Overdiagnosis Conference
  1. 1Institute of General Practice, Universitätsklinikum Erlangen, Germany
  2. 2The BMJ, London, United Kingdom
  3. 3The Lisa Schwartz Foundation for Truth in Medicine Norwich, VT/USA
  4. 4Global Center for Sustainable Healthcare, Gothenburg, Sweden
  5. 5Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH/USA
  6. 6Sydney Health Literacy Lab, Wiser Healthcare, Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
  7. 7Centre of Research & Education in General Practice, Department of Public Health, Faculty of Health Sciences, University of Copenhagen; Primary Health Care Research Unit, Region Zealand and Research Unit for General Practice, Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø Odense University Hospital Odense, Denmark and Cochrane Collaboration, Oxford, United Kingdom
  8. 8Wiser Healthcare, Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
  9. 9Herrestads Healthcare Centre, Närhälsan, Denmark; Global Center for Sustainable Healthcare, Gothenburg Denmark; University, FoUUI Fyrbodal, Cochrane Sweden
  10. 10Centre of Research & Education in General Practice, Department of Public Health, Faculty of Health Sciences, University of Copenhagen; Primary Health Care Research Unit, Region Zealand, Denmark
  11. 11Institut and Polyclinic of General Practice, Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany
  12. 12Preventing Overdiagnosis Conference.

Tackling overdiagnosis will create more sustainable healthcare for people and the planet

Many healthcare systems are facing crises of excess demand, increased prevalence of chronic disease, spiralling costs, and workforce challenges which threaten their functioning.12 Recent evidence suggests that part of the increase in prevalence of “disease” is due to overdiagnosis, overtreatment, and overall low value care.3 It has been estimated that 30% of medical care is of low value or wastes resources, and 10% is harmful.4 The health sector is estimated to account for more than 5% of greenhouse gas emissions in industrialised countries—another way in which low value care threatens health.5

There is a need for more capacity in healthcare, more investment in healthcare, and more staffing in some regions, and for specialties to improve health, wellbeing, and inequality. However, the exponential expansion of medical territory in the last half century has become unsustainable, leading to soaring healthcare costs, an unreasonable treatment burden for patients, burnout among healthcare staff, and substantial harm to the planet. We need further thought and discussion about the finite financial, human, societal, and planetary resources available for healthcare and about better distribution of existing resources.

Current crises in healthcare delivery are exacerbated by ageing populations and associated multimorbidity. Policy makers, politicians, and the public need to understand how even well-meaning efforts to provide more and better healthcare inevitably amplify and reinforce these crises through overdiagnosis, overmedicalisation, and overtreatment, diverting resources from more effective options.6 These issues must be resolved if we are to achieve sustainable healthcare.

Being open to the possibility of excess healthcare, watching for the signs, and taking action to reduce it, will help ensure that all diagnostic labels are meaningful and that tests and treatments confer clinically relevant benefits. It will also help decision makers to invest their time and resources in high value healthcare, rather than on uncertain or harmful screening, technology, products, or interventions.

Controlling excess healthcare

Reducing overdiagnosis is a critical first step to controlling excess healthcare. Clinicians, thought leaders, and others who identify medical excess have a duty to share their knowledge and work to change minds and practices. This work cuts across the whole of healthcare. For example, strengthening primary care in healthcare systems can reduce overdiagnosis and enhance continuity of care, while public health is best placed to review screening programmes.7 Messages concerning low-value care can be disseminated via traditional media, or more informally via social media.

The concept of overdiagnosis should be taught as part of evidence based healthcare from the early stages of medical training. Educational opportunities and resources on overdiagnosis, evidence based healthcare, and critical thinking should also be offered to legislators, policy makers, and their staff, as well as patients and the public. This teaching should be timely, engaging, compelling, and actionable. Challenges remain in communicating the scale of overdiagnosis and illustrating the human cost, for example by putting individual faces and stories to abstract concepts and data.8

The potential for overdiagnosis is ever present in healthcare and the community needs to publicise new examples as they arise. Established screening programmes should be re-evaluated following new developments such as effective primary prevention, changes in eligible populations, or the availability of better treatments for symptomatic disease. For example, as the prevalence of smoking decreases so do the incidences of ruptured abdominal aortic aneurism and lung cancer; childhood HPV vaccinations are lowering the incidence of cervical dysplasia and cancer.910 Both have implications for the risk benefit balance of screening programmes.

Services and interventions that are redundant, low value, or harmful should be routinely identified and decommissioned.

Our global medical culture has driven excessive diagnostic testing, overmedicalisation, and overtreatment across many conditions that may harm patients, exhaust healthcare resources, and harm the planet.11 We call upon local, national, and international decision makers to more prominently and openly acknowledge these issues and take urgent steps to resolve them. Only then can we hope to create more sustainable healthcare in the future.

Footnotes

  • Competing interests: All the authors have read and understood the BMJ policy on declaration of interests and declare no competing interests except being voluntary and unpaid members of the scientific committee of the Preventing Overdiagnosis Conference. This year’s conference will be held from 14. to 16. August 2023 in Copenhagen, Denmark. https://www.cebm.ox.ac.uk/upcoming-events/preventing-overdiagnosis

  • Provenance and peer review: commissioned, not peer reviewed.

References