Medicalization of Old Age: Experiencing Healthism and Overdiagnosis in a Nordic Welfare State.

In Denmark, people are expected to take responsibility for their health, not least as their bodies age and they experience signs of physical or mental decline. Drawing on fieldwork among older Danes, I illustrate that an excessive focus on health gives rise to social and structural controversies and disparities, linking ideas of healthy behavior at the individual level with the societal framing of disease and aging. I argue that this emphasis contributes to the unwarranted diagnosis of bodily variations that naturally occur in the aging process, a phenomenon referred to as overdiagnosis, adding to a broader medicalization of old age.

Global thyroid cancer incidence trend and age-period-cohort model analysis based on Global Burden of Disease Study from 1990 to 2019.

Background: In view of the rapid increase in the incidence of thyroid cancer (TC) and the spread of overdiagnosis around the world, the quantitative evaluation of the effect of age, period and birth cohort on the incidence of TC, and the analysis of the role of different factors in the incidence trend can provide scientific basis and data support for the national health departments to formulate reasonable prevention and treatment policies. Methods: The study collated the global burden disease study data of TC incidence from 1990 to 2019, and used APC model to analyze the contribution of age, period and birth cohort to the incidence trend of TC. Results: There was an obvious unfavorable upward trend in terms of age and cohort effect all over the world. Since 2007, the growth rate of risk slowed down and the risk in female even decreased since 2012, which mainly contributed to the developed countries. In all SDI countries, 2002 is the dividing point of risk between male and female. In 2019, The global age-standardized incidence rate (ASIR) of TC in the 5 SDI countries all showed a significant upward trend, with the largest upward trend in the middle SDI countries. Conclusion: The trend of rapid increase in the incidence of TC has begun to slow down, but the global incidence of TC has obvious gender and regional/national heterogeneity. Policy makers should tailor specific local strategies to the risk factors of each country to further reduce the burden of TC.

The Economic Cost of Thyroid Cancer in France and the Corresponding Share Associated With Treatment of Overdiagnosed Cases.

OBJECTIVES: Thyroid cancer incidence in France has increased rapidly in recent decades. Most of this increase has been attributed to overdiagnosis, the major consequence of which is overtreatment. We aimed to estimate the cost of thyroid cancer management in France and the corresponding cost proportion attributable to the treatment of overdiagnosed cases. METHODS: Multiple data sources were integrated: the mean cost per patient with thyroid cancer was estimated by using the Echantillon Généraliste des Bénéficiaires data set; thyroid cancer cases attributable to overdiagnosis were estimated for 21 departments using data from the French network of cancer registries and extrapolated to the whole country; medical records from 6 departments were used to refine the diagnosis and care pathway. RESULTS: Between 2011 and 2015, 33 911 women and 10 846 men in France were estimated to be diagnosed of thyroid cancer, with mean cost per capita of €6248. Among those treated, 8114 to 14 925 women and 1465 to 3626 men were due to overdiagnosis. The total cost of thyroid cancer patient management was €203.5 million (€154.3 million for women and €49.3 million for men), of which between €59.9 million (or 29.4% of the total cost, lower bound) and €115.9 million (or 56.9% of the total cost, upper bound) attributable to treatment of overdiagnosed cases. CONCLUSIONS: The management of thyroid cancer represents not only a relevant clinical and public health problem in France but also a potentially important economic burden. Overdiagnosis and corresponding associated treatments play an important role on the total costs of thyroid cancer management.

Incidental Findings and Low-Value Care.

Incidental imaging findings are common and analogous to the results of screening tests when screening is performed of unselected, low-risk patients. Approximately 15-30% of all diagnostic imaging and 20-40% of CT examinations contain at least one incidental finding. Patients with incidental findings but low risk for disease are likely to experience length bias, lead-time bias, overdiagnosis, and overtreatment that create an illusion of benefit while conferring harm. This includes incidental detection of many types of cancers that, although malignant, would have been unlikely to affect a patient's health had the cancer not been detected. Detection of some incidental findings can improve health, but most do not. Greater patient- and disease-related risk increase the likelihood an incidental finding is important. Clinical guidelines for incidental findings should more deeply integrate patient risk factors and disease aggressiveness to inform management. Lack of outcome and cost-effectiveness data has led to reflexive management strategies for incidental findings that promote low-value and sometimes harmful care.

Sociodemographic Disparities in Attention-Deficit/Hyperactivity Disorder Overdiagnosis and Overtreatment During Elementary School.

Attention-deficit/hyperactivity disorder (ADHD) overdiagnosis and overtreatment unnecessarily exposes children to potential harm and contributes to provider and community skepticism toward those with moderate or severe symptoms and significant impairments, resulting in less supportive care. Yet, which sociodemographic groups of children are overdiagnosed and overtreated for ADHD is poorly understood. We conducted descriptive and logistic regression analyses of a population-based subsample of 1,070 U.S. elementary schoolchildren who had displayed above-average levels of independently assessed behavioral, academic, or executive functioning the year prior to their initial ADHD diagnoses and who did not have prior diagnostic histories. Among these children, (a) 27% of White children versus 19% of non-White children were later diagnosed with ADHD and (b) 20% of White children versus 14% of non-White children were later using medication. In adjusted analyses, White children are more likely to later be diagnosed (odds ratio [OR] range = 1.70-2.62) and using medication (OR range = 1.70-2.37) among those whose prior behavioral, academic, and executive functioning suggested that they were unlikely to have ADHD.

Low-Value Care: Convergence and Challenges Comment on "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands".

Interest has increased in the topic of de-implementation, ie, reducing so-called low-value care (LVC). The article "Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands" by Verkerk and colleagues identifies national-level factors affecting LVC use in those three countries. This commentary raises three critical points regarding the study. First, the study does not clearly define the national level. Secondly, national-level factors might not be relevant for all types of LVCs and thirdly, the study's rather limited sample makes it difficult to draw firm conclusions. We also include some critical comments related to some of the study's findings in relation to results of our recently published scoping review of the international literature on de-implementation and use of LVC and an interview study with primary care physicians on LVC use. Finally, we provide some suggestions for further research that we believe is needed to improve understanding of LVC use and facilitate its de-implementation.

Psychiatrization in mental health care: The emergency department.

Background: In the light of high incidences of diagnosed mental disorders and the growing utilization of mental healthcare services, a progressing psychiatrization of society has been hypothesized as the underlying dynamic of these developments. Mental healthcare institutions, such as psychiatric hospitals, may play a decisive role in this. However, there is a scarcity of research into how psychiatrization emerges in hospital settings. This paper explores whether the emergency department (ED) can be considered as a site where psychiatrization happens, becomes observable, and which factors in the context of the ED may be its potential drivers. Methods: Two cases as encountered in an interdisciplinary ED will be presented in the following in an anonymized way. Although the cases originate from individual consultations, they can be considered as prototypical. The cases were collected and discussed using the method of interactive interviewing. The results will be analyzed against the backdrop of current theoretic concepts of psychiatrization. Findings: The ED can be seen as an important area of contact between society and psychiatry. Decisions whether to label a certain condition as a "mental disorder" and to therefore initiate psychiatric treatment, or not, can be highly difficult, especially in cases where the (health) concerns are rather moderate, and clearly associated with common life problems. Psychiatrists' decisions may be largely influenced in favor of psychiatrization by a wide array of disciplinary, institutional, interpersonal, personal, cultural, and social factors. Conclusions: The ED appears to be a promising field for research into the mechanisms and motives through which psychiatrization may emerge in mental healthcare settings. Psychiatrists in the ED work within a complex sphere of top-down and bottom-up drivers of psychiatrization. Encounters in the ED can be an important step toward adequate support for many individuals, but they also risk becoming the starting point of psychiatrization by interpreting certain problems through the psychiatric gaze, which may induce diagnoses of questionable validity and treatment of little use.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Epidemiology and challenges in the management of thyroid nodules.

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with epidemiology and challenges in the management of thyroid nodules.

Demonstrating the undermining of science and health policy after the Fukushima nuclear accident by applying the Toolkit for detecting misused epidemiological methods.

It is well known that science can be misused to hinder the resolution (i.e., the elimination and/or control) of a health problem. To recognize distorted and misapplied epidemiological science, a 33-item "Toolkit for detecting misused epidemiological methods" (hereinafter, the Toolkit) was published in 2021. Applying the Toolkit, we critically evaluated a review paper entitled, "Lessons learned from Chernobyl and Fukushima on thyroid cancer screening and recommendations in the case of a future nuclear accident" in Environment International in 2021, published by the SHAMISEN (Nuclear Emergency Situations - Improvement of Medical and Health Surveillance) international expert consortium. The article highlighted the claim that overdiagnosis of childhood thyroid cancers greatly increased the number of cases detected in ultrasound thyroid screening following the 2011 Fukushima nuclear accident. However, the reasons cited in the SHAMISEN review paper for overdiagnosis in mass screening lacked important information about the high incidence of thyroid cancers after the accident. The SHAMISEN review paper ignored published studies of screening results in unexposed areas, and included an invalid comparison of screenings among children with screenings among adults. The review omitted the actual state of screening in Fukushima after the nuclear accident, in which only nodules > 5 mm in diameter were examined. The growth rate of thyroid cancers was not slow, as emphasized in the SHAMISEN review paper; evidence shows that cancers detected in second-round screening grew to more than 5 mm in diameter over a 2-year period. The SHAMISEN consortium used an unfounded overdiagnosis hypothesis and misguided evidence to refute that the excess incidence of thyroid cancer was attributable to the nuclear accident, despite the findings of ongoing ultrasound screening for thyroid cancer in Fukushima and around Chernobyl. By our evaluation, the SHAMISEN review paper includes 20 of the 33 items in the Toolkit that demonstrate the misuse of epidemiology. The International Agency for Research on Cancer meeting in 2017 and its publication cited in the SHAMISEN review paper includes 12 of the 33 items in the Toolkit. Finally, we recommend a few enhancements to the Toolkit to increase its utility.

Tools to Reduce Low-Value Care: Lessons From COVID-19 Pandemic Comment on "Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands".

Based on a summary of interviews with 18 experts, Verkerk et al defined the seven key factors that promoted low-value care, which included system, social, and knowledge factors. During the ongoing coronavirus disease 2019 (COVID-19) pandemic, these key factors have been influential due to the uncertainty of the disease at the beginning of the pandemic. Globally, several measures have been implemented to reduce low-value care practices and promote high-value care for COVID-19 patients. From huge multicenter, non-industry sponsored or multiplatform trials, to the use of social networks sites is an indispensable and effective way to disseminate medical information. Thanks to these measures, we have transformed a scenario of ignorance into an evidence-based medical scenario in less than a year. Verkerk and colleagues' proposed key factors are an excellent framework for characterizing and highlighting the lessons that can be learnt from how we have fought against the pandemic and low-value practices.

Assessment of prostate-specific antigen screening: an evidence-based report by the German Institute for Quality and Efficiency in Health Care.

CONTEXT: Prostate-specific antigen (PSA) testing increases prostate cancer diagnoses and reduces long-term disease-specific mortality, but also results in overdiagnoses and treatment-related harms. OBJECTIVE: To systematically assess the benefits and harms of population-based PSA screening and the potential net benefit to inform health policy decision-makers in Germany. EVIDENCE ACQUISITION: We performed a protocol-guided comprehensive literature search according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. All steps were performed by one or two investigators; any discrepancies were resolved by consensus. To allow subgroup analyses for identifying the optimal screening parameters, the eight national trials conducted under the umbrella of the European Randomised study of Screening for Prostate Cancer (ERSPC) were included as individual trials. EVIDENCE SYNTHESIS: We included a total 11 randomised controlled trials (RCTs) with a total of 416 000 study participants. For all-cause mortality, we found neither benefit nor harm. PSA screening was associated with a reduced risk of both prostate cancer mortality and the development of metastases. For the outcomes of health-related quality of life, adverse effects and the consequences of false-negative screening results there was no difference; however, this was due to the lack of eligible RCT data. Finally, PSA screening was associated with large numbers of overdiagnoses with adverse downstream consequences of unnecessary treatment (e.g. incontinence, erectile dysfunction) and large numbers of false-positive PSA tests leading to biopsies associated with a small but not negligible risk of complications. Limitations of this assessment include the clinical heterogeneity and methodological limitations of the underlying studies. CONCLUSIONS: The benefits of PSA-based prostate cancer screening do not outweigh its harms. We failed to identify eligible screening studies of newer biomarkers, PSA derivatives or modern imaging modalities, which may alter the balance of benefit to harm. PATIENT SUMMARY: In the present study, we reviewed the evidence on the PSA blood test to screen men without symptoms for prostate cancer. We found that the small benefits experienced by some men do not outweigh the harms to many more men.

Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands.

BACKGROUND: Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries. METHODS: We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis. RESULTS: The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy. CONCLUSION: Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

UK Women's Views of the Concepts of Personalised Breast Cancer Risk Assessment and Risk-Stratified Breast Screening: A Qualitative Interview Study.

Any introduction of risk-stratification within the NHS Breast Screening Programme needs to be considered acceptable by women. We conducted interviews to explore women's attitudes to personalised risk assessment and risk-stratified breast screening. Twenty-five UK women were purposively sampled by screening experience and socioeconomic background. Interview transcripts were qualitatively analysed using Framework Analysis. Women expressed positive intentions for personal risk assessment and willingness to receive risk feedback to provide reassurance and certainty. Women responded to risk-stratified screening scenarios in three ways: 'Overall acceptors' considered both high- and low-risk options acceptable as a reasonable allocation of resources to clinical need, yet acceptability was subject to specified conditions including accuracy of risk estimates and availability of support throughout the screening pathway. Others who thought 'more is better' only supported high-risk scenarios where increased screening was proposed. 'Screening sceptics' found low-risk scenarios more aligned to their screening values than high-risk screening options. Consideration of screening recommendations for other risk groups had more influence on women's responses than screening-related harms. These findings demonstrate high, but not universal, acceptability. Support and guidance, tailored to screening values and preferences, may be required by women at all levels of risk.

Cost effectiveness of breast cancer screening and prevention: a systematic review with a focus on risk-adapted strategies.

OBJECTIVES: Benefit and cost effectiveness of breast cancer screening are still matters of controversy. Risk-adapted strategies are proposed to improve its benefit-harm and cost-benefit relations. Our objective was to perform a systematic review on economic breast cancer models evaluating primary and secondary prevention strategies in the European health care setting, with specific focus on model results, model characteristics, and risk-adapted strategies. METHODS: Literature databases were systematically searched for economic breast cancer models evaluating the cost effectiveness of breast cancer screening and prevention strategies in the European health care context. Characteristics, methodological details and results of the identified studies are reported in evidence tables. Economic model outputs are standardized to achieve comparable cost-effectiveness ratios. RESULTS: Thirty-two economic evaluations of breast cancer screening and seven evaluations of primary breast cancer prevention were included. Five screening studies and none of the prevention studies considered risk-adapted strategies. Studies differed in methodologic features. Only about half of the screening studies modeled overdiagnosis-related harms, most often indirectly and without reporting their magnitude. All models predict gains in life expectancy and/or quality-adjusted life expectancy at acceptable costs. However, risk-adapted screening was shown to be more effective and efficient than conventional screening. CONCLUSIONS: Economic models suggest that breast cancer screening and prevention are cost effective in the European setting. All screening models predict gains in life expectancy, which has not yet been confirmed by trials. European models evaluating risk-adapted screening strategies are rare, but suggest that risk-adapted screening is more effective and efficient than conventional screening.

Exploring physicians and patients' perspectives for current interventions on thyroid nodules using a MCDA method.

BACKGROUND: The detection of thyroid cancer has rapidly increased over last few decades without an increase in disease specific mortality. Several studies claim that the diagnose of thyroid nodules through routine ultrasound imaging is often the trigger for cascade effects leading to unnecessary follow-up over many years or to invasive treatment. The objective of this study was to explore physicians' and patients' insights and preferences regarding the current interventions on thyroid nodules. METHODS: An online survey was developed using a comprehensive multi-criteria decision analysis (MCDA) framework, the EVIdence based Decision-Making (EVIDEM). The EVIDEM core model used in this study encompassed 13 quantitative criteria and four qualitative criteria. Participants were asked to provide weights referring to what matters most important in general for each criterion, performance scores for appraising the interventions on thyroid nodules and their consideration of impact of contextual criteria. Normalized weights and standardized scores were combined to calculate a value contribution across all participants, additionally differences across physicians and patients' group were explored. RESULTS: 48 patients and 31 physicians were included in the analysis. The value estimate of the interventions on thyroid nodules reached 0.549 for patients' group and 0.5 was reported by the physicians' group, compared to 0.543 for all participants. The highest value contributor was 'Comparative effectiveness' (0.073 ± 0.020). For the physicians' group, 'Comparative safety' (0.050 ± 0.023) was given with higher value. And for the patients' group, 'Type of preventive benefits' (0.059 ± 0.022) contributed more positively to the value estimation. 51% participants considered 'Population priorities and access' having a negative impact on the interventions of nodules.66% participants thought that the 'system capacity' had a negative impact. CONCLUSION: Our study shows participants' preferences on each criterion, i.e., physician indicated keeping the interventions safe and effective more important, patients indicated quality of life after receiving interventions more important. Through comparison among participants, differences have been highlighted, which can make better communication between physicians and patients. This study provides a supportive decision-making for healthcare providers when they explored the interventions on thyroid nodules.

Income differences in screening, incidence, postoperative complications, and mortality of thyroid cancer in South Korea: a national population-based time trend study.

BACKGROUND: The incidence of thyroid cancer (TC) has increased rapidly over the past few decades in Korea. This study investigated whether the TC epidemic has been driven by overdiagnosis. METHODS: We calculated the TC screening rate from mid-2008 through mid-2014, and the incidence, postoperative complication, and mortality rates of TC between 2006 and 2015, using data from the Korea Community Health Survey, the National Health Insurance Database, and the cause-of-death data of Statistics Korea. Trends in age-standardized rates of all indicators were examined, along with income gaps therein. Analyses were conducted for lung cancer and stroke as negative control outcomes. RESULTS: The incidence rate of TC increased from 46.6 per 100,000 to 115.0 per 100,000 between 2006 and 2012, and then decreased to 63.5 per 100,000 in 2015. Despite these remarkable changes in incidence, mortality did not fluctuate during the same period. High income was associated with high rates of screening, incidence, and postoperative complications, while low income showed an association with a high mortality rate. Analyses using negative control outcomes showed that high income was associated with low rates of both incidence and mortality, which contrasted with the patterns of TC. The recent decreases in TC incidence and postoperative complications, which reflect societal concerns about the overdiagnosis of TC, were more pronounced in high-income individuals than in low-income individuals. CONCLUSIONS: The time trends in income gaps in screening, incidence, postoperative complications, and mortality of TC, as well as negative control outcomes, provided corroborating evidence of TC overdiagnosis in Korea.

The "unfortunate experiment" that was not, and the indebtedness of women and children to Herbert ("Herb") Green (1916-2001).

All screening programs have the potential to result in harmful overdiagnosis and overtreatment. Sound evidence, policy, and standards are needed to keep this harm to a minimum. Screening for and "treating" cervical cytological abnormalities provides a sobering example. The term "carcinoma in situ" came into use from 1950 and implied-misleadingly-that an inevitable malignant process had been identified. Hysterectomy became widely used to "treat" it. New Zealand's Herbert Green was one of a minority of gynecologists around the world who recognized the possible dangers of harmful overtreatment. Green developed and monitored more conservative management approaches to avoid women being "subjected to hysterectomy". By the mid-1980s, his approaches had been adopted not only within National Women's Hospital in Auckland, but more widely. In 1987, it was alleged in a magazine article that an "experimental" research program had been undertaken at National Women's Hospital to study the natural course of untreated cervical "carcinoma in situ"; that this had entailed withholding "conventional treatment" from some patients indefinitely; and that some patients had died as a result. A public furore resulted and led 2 weeks later to the creation of a judicial inquiry-the Cartwright Inquiry-which reported the following year. The findings of the Inquiry, which criticized Green's practice, have been both disputed and defended ever since, often by individuals with competing interests. In the recently published 2nd edition of their book Screening: Evidence and Practice, Angela Raffle, Anne Mackie, and Muir Gray have provided a fresh analysis. This concludes (see accompanying article) that the Cartwright Inquiry provides no trustworthy evidence of harm from the adoption of the conservative management introduced by Green and adopted by some of his colleagues at National Women's Hospital. It is now clear that the treatment and monitoring methods introduced by Herb Green have benefited numerous women through avoidance of major surgery and preservation of fertility.

Epistemic risks in cancer screening: Implications for ethics and policy.

Cancer screening is the subject of much debate; while screening has the potential to save lives by identifying and treating cancers in early stages, it is also the case that not all cancers cause symptoms, and the diagnosis of these cancers can lead to unnecessary treatments and subsequent side-effects and complications. This paper explores the relationships between epistemic risks in cancer diagnosis and screening, the social organization of medical research and practice, and policy making; it does this by examining 2018 recommendations by the United States Preventative Services Task Force that patients make individualized, autonomy-based decisions about cancer screening on the basis of discussions with their physicians. While the paper focuses on prostate cancer screening, the issues that it raises are relevant to other cancer screening programs, especially breast cancer. The paper argues that prostate cancer screening-and, more generally, the process of risk assessment for prostate cancer-is pervaded by epistemic risks that reflect value judgments and that the pervasiveness of these epistemic risks creates significant and under-explored difficulties for physician-patient communication and the achievement of autonomous patient decision making.

Controversies in diagnosis: contemporary debates in the diagnostic safety literature.

Since the 2015 publication of the National Academy of Medicine's (NAM) Improving Diagnosis in Health Care (Improving Diagnosis in Health Care. In: Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press, 2015.), literature in diagnostic safety has grown rapidly. This update was presented at the annual international meeting of the Society to Improve Diagnosis in Medicine (SIDM). We focused our literature search on articles published between 2016 and 2018 using keywords in Pubmed and the Agency for Healthcare Research and Quality (AHRQ)'s Patient Safety Network's running bibliography of diagnostic error literature (Diagnostic Errors Patient Safety Network: Agency for Healthcare Research and Quality; Available from: https://psnet.ahrq.gov/search?topic=Diagnostic-Errors&f_topicIDs=407). Three key topics emerged from our review of recent abstracts in diagnostic safety. First, definitions of diagnostic error and related concepts are evolving since the NAM's report. Second, medical educators are grappling with new approaches to teaching clinical reasoning and diagnosis. Finally, the potential of artificial intelligence (AI) to advance diagnostic excellence is coming to fruition. Here we present contemporary debates around these three topics in a pro/con format.

Direct costs of overdiagnosed asthma: a longitudinal, population-based cohort study in British Columbia, Canada.

OBJECTIVES: A current diagnosis of asthma cannot be objectively confirmed in many patients with physician-diagnosed asthma. Estimates of resource use in overdiagnosed cases of asthma are necessary to measure the burden of overdiagnosis and to evaluate strategies to reduce this burden. We assessed differences in asthma-related healthcare resource use between patients with a confirmed asthma diagnosis and those with asthma ruled out. DESIGN: Population-based, prospective cohort study. SETTING: Participants were recruited through random-digit dialling of both landlines and mobile phones in the province of British Columbia, Canada. PARTICIPANTS: We included 345 individuals ≥12 years of age with a self-reported physician diagnosis of asthma. The diagnosis of asthma was reassessed at the end of 12 months of follow-up using a structured algorithm, which included a bronchodilator reversibility test, methacholine challenge test, and if necessary medication tapering and a second methacholine challenge test. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported annual asthma-related direct healthcare costs (2017 Canadian dollars), outpatient physician visits and medication use from the perspective of the Canadian healthcare system. RESULTS: Asthma was ruled out in 86 (24.9%) participants. The average annual asthma-related direct healthcare costs for participants with confirmed asthma were $C497.9 (SD $C677.9) and for participants with asthma ruled out, $C307.7 (SD $C424.1). In the adjusted analyses, a confirmed diagnosis was associated with higher direct healthcare costs (relative ratio (RR)=1.60, 95% CI 1.14 to 2.22), increased rate of specialist visits (RR=2.41, 95% CI 1.05 to 5.40) and reliever medication use (RR=1.62, 95% CI 1.09 to 2.35), but not primary care physician visits (p=0.10) or controller medication use (p=0.11). CONCLUSIONS: A quarter of individuals with a physician diagnosis of asthma did not have asthma after objective re-evaluation. These participants still consumed a significant amount of asthma-related healthcare resources. The population-level economic burden of asthma overdiagnosis could be substantial.