Attitudes, knowledge and practice regarding the anti-müllerian hormone test among general practitioners and reproductive specialists: A cross-sectional study.

OBJECTIVE: To describe clinicians' attitudes, knowledge and practice relating to the anti-müllerian hormone (AMH) test. DESIGN: Cross-sectional nationwide survey. SETTING: Australia. POPULATION OR SAMPLE: A total of 362 general practitioners (GPs), gynaecologists and reproductive specialists. METHODS: Clinicians were recruited through relevant professional organisations, with data collected from May 2021 to April 2022. MAIN OUTCOME MEASURES: Clinicians' attitudes, knowledge and practice relating to the AMH test, measured using multiple choice, Likert scales and open-ended items. RESULTS: Fifteen percent of GPs (n = 27) and 40% of gynaecologists and other specialists (n = 73) order at least one AMH test per month. Specialists reported raising the idea of testing most of the time, whereas GPs reported that patient request was more common. Half of clinicians lacked confidence interpreting (n = 182, 51%) and explaining (n = 173, 48%) an AMH result to their patients. Five percent (n = 19) believed the test was moderately/very useful in predicting natural conception/birth and 22% (n = 82) believed the same for predicting premature menopause, despite evidence that the test cannot reliably predict either. Forty percent (n = 144) had previously ordered the test to help with reproductive planning and 21% (n = 75) to provide reassurance about fertility. CONCLUSIONS: Clinicians reported use of AMH testing in clinical circumstances not supported by the evidence. With the proliferation of direct-to-consumer testing, efforts to support clinicians in the judicious use of testing and effectively navigating patient requests are needed.

First implantable cardiac defibrillator insertions in New South Wales, 2005-2020: an analysis of linked administrative data.

OBJECTIVES: To determine the annual numbers of first ICD insertions in New South Wales during 2005-2020; to examine health outcomes for people who first received ICDs during this period. STUDY DESIGN: Retrospective cohort study; analysis of linked administrative health data. SETTING, PARTICIPANTS: All first insertions of ICDs in NSW, 2005-2020. MAIN OUTCOME MEASURES: Annual numbers of first ICD insertions, and of emergency department presentations and hospital re-admissions 30 days, 90 days, 365 days after first ICD insertions; all-cause and disease-specific mortality (to ten years after ICD insertion). RESULTS: During 2005-2020, ICDs were first inserted into 16 867 people (18.5 per 100 000 population); their mean age was 65.7 years (standard deviation, 13.5 years; 7376 aged 70 years or older, 43.7%), 13 214 were men (78.3%). The annual number of insertions increased from 791 in 2005 to 1256 in 2016; the first ICD insertion rate increased from 15.5 in 2005 to 18.9 per 100 000 population in 2010, after which the rate was stable until 2019 (19.8 per 100 000 population). Of the 16 778 people discharged alive from hospital after first ICD insertions, 54.4% presented to emergency departments within twelve months, including 1236 with cardiac arrhythmias (7.4%) and 434 with device-related problems (2.6%); 56% were re-admitted to hospital, including 1944 with cardiac arrhythmias (11.5%) and 2045 with device-related problems (12.1%). A total of 5624 people who received first ICDs during 2005-2020 (33.3%) died during follow-up (6.7 deaths per 100 person-years); the survival rate was 94.4% at one year, 76.5% at five years, and 54.2% at ten years. CONCLUSIONS: The annual number of new ICDs inserted in NSW has increased since 2005. A substantial proportion of recipients experience device-related problems that require re-admission to hospital. The potential harms of ICD insertion should be considered when assessing the likelihood of preventing fatal ventricular arrhythmia.

Genitourinary Syndrome of Menopause: Does Everyone Have It?

In 2014, the North American Menopause Society and the International Society for the Study of Women's Sexual Health recommended using the term genitourinary syndrome of menopause (GSM) to cover a range of genital and urinary symptoms that might be experienced during and after menopause. The term as currently defined, however, includes symptoms that may not be menopausal symptoms. The term GSM also includes "objective" measures such as vaginal pH that do not relate to symptom severity and are not priorities for clinicians or patients. We question the validity of GSM as a new syndrome and recommend the definition of the syndrome be revised to ensure it more closely reflects the symptoms attributable to menopause and the experience, difficulties, and response to treatment of those affected.

Community awareness and use of anti-Müllerian hormone testing in Australia: a population survey of women.

STUDY QUESTION: What is the anti-Mullerian hormone (AMH) test usage, awareness, and perceived reasons for testing in a representative community sample of women in Australia? SUMMARY ANSWER: : Among women aged 18-55 years, 13% had heard about AMH testing and 7% had had an AMH test, with the top three reasons for testing including due to infertility investigations (51%), considering pregnancy and wanting to understand their chances (19%) or to find out if a medical condition had affected fertility (11%). WHAT IS KNOWN ALREADY: The growing availability of direct-to-consumer AMH testing has raised concerns about overuse, however as most AMH tests are paid for privately by consumers, data on test usage is not publicly available. STUDY DESIGN, SIZE, DURATION: National cross-sectional survey of 1773 women, conducted in January 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Females aged 18-55 years were recruited from the representative 'Life in Australia' probability-based population panel and completed the survey online or by telephone. Main outcome measures included if and how participants had heard about AMH testing, whether they had ever had an AMH test, main reason for testing and test access. MAIN RESULTS AND THE ROLE OF CHANCE: Of the 2423 women who were invited 1773 responded (73% response rate). Of these, 229 (13%) had heard about AMH testing and 124 (7%) had had an AMH test. Testing rates were highest among those currently aged 35-39 years (14%) and associated with educational attainment. Almost all accessed the test through their general practitioner or fertility specialist. Reasons for testing were: part of an infertility investigation (51%), considering pregnancy and wanting to understand chances of conceiving (19%), finding out if a medical condition had affected fertility (11%), curiosity (9%), considering egg freezing (5%), and considering delaying pregnancy (2%). LIMITATIONS, REASONS FOR CAUTION: Although the sample was large and mostly representative, it was over-represented by people holding a university degree and under-represented by people aged 18-24, however, we used weighted data where possible to account for this. All data were self-reported so there is a risk of recall bias. The number of survey items was also restricted, so the type of counselling women received prior to testing, reasons for declining an AMH test or test timing were not measured. WIDER IMPLICATIONS OF THE FINDINGS: Whilst most women reported having an AMH test for appropriate reasons, about one third had it for reasons not supported by evidence. Public and clinician education about the lack of utility of AMH testing for women not undergoing infertility treatment is needed. STUDY FUNDING/COMPETING INTEREST(S): This project was supported by a National Health and Medical Research Council (NHMRC) Centre for Research Excellence grant (1104136) and Program grant (1113532). T.C. is supported by an NHMRC Emerging Leader Research Fellowship (2009419). B.W.M. reports research funding, consultancy and travel support from Merck. D.L. is the Medical Director of City Fertility NSW and reports consultancy for Organon, Ferring, Besins and Merck. The authors have no other competing interests. TRIAL REGISTRATION NUMBER: N/A.

Associations between endometriosis and common symptoms: findings from the Australian Longitudinal Study on Women's Health.

BACKGROUND: Endometriosis has been linked to higher rates of a variety of symptoms; however, the findings from longitudinal studies are scarce and inconsistent. OBJECTIVE: This study aimed to examine the association between endometriosis and common symptoms in a prospective cohort study. STUDY DESIGN: This study included 7606 women born from 1973 to 1978 using data from the Australian Longitudinal Study on Women's Health that were collected every 3 years from 2009 to 2018. We identified women with endometriosis based on self-reported incidence from each survey and linked administrative health data. At each survey, women also completed a checklist on the presence of 24 symptoms. Generalized estimating equations for multinomial responses were used for analyses. RESULTS: Women with endometriosis had significantly more menstrual symptoms than those without endometriosis with an adjusted odds ratio (95% confidence interval) of 3.61 (3.11-4.19) for severe period pain, 2.40 (2.10-2.74) for heavy menstrual bleeding, 1.76 (1.52-2.03) for irregular bleeding, and 1.52 (1.32-1.76) for premenstrual tension. They also had higher odds of mental health problems with adjusted odds ratios of 1.67 (1.39-2.01) for depression and 1.59 (1.24-2.03) for anxiety and higher odds of allergies and nonspecific symptoms with adjusted odds of 1.62 (1.40-1.89) for allergies or hay fever or sinusitis, 1.79 (1.56-2.05) for severe tiredness, 1.56 (1.35-1.81) for sleep difficulty, and 1.77 (1.37-2.18) for palpitations. There was also a strong association with other forms of pain with an adjusted odds ratio of 1.76 (1.53-2.04) for backpain, 1.50 (1.29-1.74) for headaches or migraines, and 1.65 (1.41-1.93) for stiff or painful joints. Women with endometriosis also had increased odds of developing bowel and urinary symptoms with an adjusted odds ratio (95% confidence interval) of 1.67 (1.35-2.08) for constipation, 1.46 (1.12-1.90) for hemorrhoids or piles, 1.25 (1.03-1.52) for indigestion or heartburn, 2.80 (1.71-4.58) for urine burn or stings, and 1.37 (1.03-1.82) for vaginal discharge or irritation. The association between each symptom and endometriosis was similar whether endometriosis was surgically confirmed or clinically suspected. No association was found between endometriosis and the risk for skin problems, leaking urine, or breathing difficulty. CONCLUSION: This study suggests that women with endometriosis are more likely to report not only menstrual symptoms but are also at an increased risk for mental health problems, other pain symptoms, bowel and urinary symptoms, and nonspecific symptoms, such as severe tiredness and difficulty sleeping.

Coping with uncertainty in clinical practice: a narrative review.

Clinicians must make decisions amid the uncertainty that is ubiquitous to clinical practice. Uncertainty in clinical practice can assume many forms depending on its source, such as insufficient personal knowledge or scientific evidence, limited practical understanding or competence, challenging interpersonal relationships, and complexity and ambiguity in clinical encounters. The level and experience of uncertainty varies according to personal traits, clinical context, affective factors and sociocultural norms. Clinicians vary in their tolerance of uncertainty, and maladaptive responses may adversely affect patient care and clinician wellbeing. Various strategies can be used to minimise and manage, but not eliminate, uncertainty and to share uncertainty with patients without compromising the clinician-patient relationship or clinician credibility.

Excess healthcare costs of psychological distress in young women: Evidence from linked national Medicare claims data.

The prevalence of mental health disorders in young adults is increasing, yet there is limited empirical evidence on its economic consequences. We contribute to the literature by estimating the healthcare costs of psychological distress using panel data of young women (aged 18-23 years with a 5-year follow-up) from the Australian Longitudinal Study on Women's Health and linked administrative data from Medicare Australia. Our empirical strategy is based on the classical two-part model of healthcare costs with individual specific fixed-effects. We complement our analysis with a test for selection on unobservables to address potential concerns of endogeneity. We find that young women with psychological distress have 15% higher annual healthcare costs (excluding hospital costs) than women with no psychological distress. A large proportion of these costs is driven by the use of antidepressants and the services of psychiatrists and psychologists. We further find that women with psychological distress have higher out-of-pocket costs on these mental health related services compared to non-mental health specific services. Additionally, we show that the effect of psychological distress on healthcare costs is highest during the first 6 months of onset, which gradually decreases afterwards. The findings justify the importance of policy initiatives towards early prevention and treatment of psychological distress, especially among young women.

Symptom patterns and health service use of women in early adulthood: a latent class analysis from the Australian Longitudinal Study on Women's Health.

BACKGROUND: Symptoms can be strong drivers for initiating interaction with the health system, especially when they are frequent, severe or impact on daily activities. Research on symptoms often use counts of symptoms as a proxy for symptom burden, however simple counts don't provide information on whether groups of symptoms are likely to occur together or whether such groups are associated with different types and levels of healthcare use. Women have a higher symptom burden than men; however studies of symptom patterns in young women are lacking. We aimed to characterise subgroups of women in early adulthood who experienced different symptom patterns and to compare women's use of different types of health care across the different symptom subgroups. METHODS: Survey and linked administrative data from 7 797 women aged 22-27 years in 2017 from the 1989-95 cohort of the Australian Longitudinal Study on Women's Health were analysed. A latent class analysis was conducted to identify subgroups of women based on the frequency of 16 symptom variables. To estimate the associations between the latent classes and health service use, we used the "Bolck, Croon and Hagenaars" (BCH) approach that takes account of classification error in the assignment of women to latent classes. RESULTS: Four latent classes were identified, characterised by 1) low prevalence of most symptoms (36.6%), 2) high prevalence of menstrual symptoms but low prevalence of mood symptoms (21.9%), 3) high prevalence of mood symptoms but low prevalence of menstrual symptoms, (26.2%), and high prevalence of many symptoms (15.3%). Compared to the other three classes, women in the high prevalence of many symptoms class were more likely to visit general practitioners and specialists, use more medications, and more likely to have had a hospital admission. CONCLUSIONS: Women in young adulthood experience substantially different symptom burdens. A sizeable proportion of women experience many co-occurring symptoms across both physical and psychological domains and this high symptom burden is associated with a high level of health service use. Further follow-up of the women in our study as they enter their late 20 s and early 30 s will allow us to examine the stability of the classes of symptoms and their associations with general health and health service use. Similar studies in other populations are needed to assess the generalisability of the findings.

The impact of health literacy on psychosocial and behavioural outcomes among people at low risk of cardiovascular disease.

This study aimed to explore the impact of health literacy on psychosocial and behavioural outcomes for people who were not at high risk of cardiovascular disease receiving a hypothetical blood pressure reading of 135/85 mmHg. We performed a secondary analysis of data from a national sample of Australians aged 40 to 50 years (n = 1318) recruited online. Health literacy was measured using the validated Newest Vital Sign (inadequate: 0-3; adequate: 4-6). Analysed outcomes included: willingness to increase exercise and accept medication; perceived severity; positive and negative affect; illness perceptions and impacts on life and motivation. Participants with inadequate levels of health literacy perceived a blood pressure reading of 135/85 mmHg to be less serious compared to individuals with adequate health literacy (Mean Difference [MD]:0.21; 95%CI 0.03-0.39; p = .024; d = 0.13), and reported less motivation to eat well (MD:0.44; 95%CI 0.31-0.58; p < .001; d = 0.38) and exercise (MD:0.43; 95%CI 0.31-0.58; p < .001; d = 0.36). However, they were more willing to accept medication (MD:0.20; 95%CI 0.07-0.34; p = .004; d = 0.17). Participants with inadequate health literacy also perceived the condition to have fewer negative impacts on aspects of life and work than individuals with adequate health literacy, but reported greater negative emotion and more negative illness perceptions (all p < .001). Tailored communication and behaviour change support may be needed when communicating blood pressure information to people with lower health literacy and not at high risk of cardiovascular disease given the differential impacts on medication (increased willingness) and healthy exercise and diet behaviours (decreased willingness) observed in this study.

Socioeconomic, behavioural and health factors associated with chlamydia testing in sexually active young women: an Australian observational cohort study.

BACKGROUND: Chlamydia trachomatis is the most frequently notified sexually transmitted infection in Australia. Untreated infections in women can cause health problems. Professional guidelines encourage opportunistic testing of young people. To increase understanding of who is being tested, we investigated factors associated with testing in a population of young women. METHODS: In total, 14002 sexually active women, aged 18-23 years at baseline (2013), from the Australian Longitudinal Study on Women's Health, were included. We used random intercepts, mixed-effects binary logistic regression with robust standard errors to assess associations between socioeconomic, health and behavioural factors and chlamydia testing. RESULTS: Associations between chlamydia testing and partner status varied by a woman's body mass index (BMI). Compared to women with a stable partner/BMI <25kg/m2 , women with a stable partner/BMI ≥25kg/m2 were less likely to be tested (adjusted odds ratios [AOR]=0.79, 95% CI: 0.71-0.88). In contrast, although women without a partner were more likely to be tested irrespective of BMI, the odds were higher for those with a BMI <25kg/m2 (AOR=2.68, 95% CI: 2.44-2.94) than a BMI ≥25kg/m2 (AOR=1.65, 95% CI: 1.48-1.84). Women who reported a prior chlamydia infection were also more likely to be tested (AOR=2.01, 95% CI: 1.83-2.20), as were women engaging in any combination of cannabis use and/or heavy episodic drinking compared to doing neither of these activities. CONCLUSIONS: Women without a partner, women with a prior chlamydia infection and those engaging in risk-taking behaviours are more likely to have chlamydia testing. Additional research is needed to understand whether there are deficits in testing among overweight/obese women.

Clinicians' perspectives on gestational diabetes screening during the global COVID-19 pandemic in Australia.

AIM: There is no international consensus for the screening and diagnosis of gestational diabetes mellitus (GDM). In March 2020, modified screening and diagnostic recommendations were rapidly implemented in Queensland, Australia, in response to the COVID-19 pandemic. How clinicians perceived and used these changes can provide insights to support high-quality clinical practice and provide lessons for future policy changes. The aim of this study was to understand clinicians' perceptions and use of COVID-19 changes to GDM screening and diagnostic recommendations. METHODS: Queensland healthcare professionals responsible for diagnosing or caring for women with GDM were recruited for semi-structured telephone interviews. Data analysis of transcribed interviews used inductive reflexive thematic analysis. RESULTS: Seventeen interviews were conducted with the following participants: six midwives/nurses, three endocrinologists, two general practitioners, two general practitioners/obstetricians, two diabetes educators, one dietitian and one obstetrician. Three themes emerged: communication and implementation, perceptions and value of evidence and diversity in perceptions of GDM screening. Overall, clinicians welcomed the rapid changes during the initial uncertainty of the pandemic, but as COVID-19 became less of a threat to the Queensland healthcare system, some questioned the underlying evidence base. In areas where GDM was more prevalent, clinicians more frequently worried about missed diagnoses, whereas others who felt that overdiagnosis had occurred in the past continued to support the changes. CONCLUSIONS: These findings highlight the challenges to changing policy when clinicians have diverse (and often strongly held) views.

Regularity and Continuity of GP Contacts and Use of Statins Amongst People at Risk of Cardiovascular Events.

BACKGROUND: Regularity and continuity of general practitioner (GP) contacts are associated with reduced hospitalisation. Opportunities for improved medication management are cited as a potential cause. OBJECTIVE: Determine associations between continuity and regularity of primary care and statin use amongst individuals at risk of cardiovascular disease (CVD) outcomes. DESIGN: Observational cohort study using self-report and administrative data from 267,153 participants of the Sax Institute's 45 and Up Study conducted in New South Wales, Australia. from 2006 to 2009. Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, from Services Australia, were linked to survey, hospital and death data by the NSW Centre for Health Record Linkage. PARTICIPANTS: The 45 and Up Study participants at risk of CVD outcomes based on self-report and administrative data, divided into existing users and potential users based on dispensing records through the exposure period. MAIN MEASURES: The Continuity of Care index (COC), measuring whether patients see the same GP, and an index assessing whether GP visits are on a regular basis, measured from July 2011 to June 2012. Amongst potential users, statin initiation from July 2012 to June 2013 was assessed using logistic regression; amongst existing users, adherence was assessed from July 2012 to June 2015 using Cox regression (non-adherence being 30 days without statins). KEY RESULTS: Amongst 29,420 potential users, the most regular quintile had 1.22 times the odds of initiating statin (95%CI 1.11-1.34), while the high continuity group had an odds ratio of 1.12 (95%CI 1.02-1.24). Amongst 30,408 existing users, the most regular quintile had 0.82 the hazard of non-adherence (95%CI 0.78-0.87); the high continuity group had a hazard ratio of 0.89 (95%CI 0.84-0.94). CONCLUSIONS: Regularity and continuity of care impact on medication management. It is possible that this mediates impacts on hospitalisation. Where there is a risk of unobserved confounding, potential causal pathways should be investigated.

Impact of diagnostic labels and causal explanations for weight gain on diet intentions, cognitions and emotions: An experimental online study.

Disease labels and causal explanations for certain symptoms or conditions have been found to have both positive and negative outcomes. For example, a diagnosis of polycystic ovary syndrome could conceivably motivate a person to engage in weight management, which is the recommended first line treatment. Furthermore, doctors may feel more comfortable discussing weight when linked to a medical condition. However, such a diagnosis may elicit feelings of increased anxiety, perceived severity and reduced sense of control. Mixed findings are also evident for impacts of genetic explanations on psychosocial outcomes and behaviours. Using hypothetical scenarios presented in an online survey, participants were asked to imagine that they were visiting their general practitioner due to experiencing weight gain, irregular periods, and more pimples than usual. Participants were randomised to receive different diagnostic labels ('polycystic ovary syndrome', 'weight' or no label/description) and causal explanations (genetic or environmental) for their symptoms. Primary outcomes assessed included intention to eat a healthier diet and perceived personal control of weight (average score on scale 1-7 across 3 items). Secondary outcomes included weight stigma, blameworthiness, worry, perceived severity, self-esteem, belief diet will reduce risks and menu item choice. Participants were 545 females aged 18-45 years (mean = 33 years), living in Australia, recruited through a national online recruitment panel. The sample was overweight on average (BMI = 26.5). Participants reporting a PCOS diagnosis were excluded from analyses. We found no main effects of the label or explanation on intention to eat healthier or perceived personal control of weight. For secondary outcomes, those given the genetic explanation reported higher weight stigma (range 1-7; MD = 0.27, 95%CI: 0.011,0.522), greater worry (range 1-7; MD = 0.27, 95%CI: 0.037,0.496), lower self-esteem (range 10-40; MD = 1.26, 95%CI: 0.28 to 2.24) and perceived their weight as more severe (range 1-7; MD = 0.28; 95%CI: 0.05,0.52) than those given the environmental explanation, averaged over disease label given. These findings further highlight the deleterious effects of genetic explanations on psychosocial outcomes and reinforce the need for caution when communicating the aetiology of weight-related health issues.

Impact of a diagnosis of polycystic ovary syndrome on diet, physical activity and contraceptive use in young women: findings from the Australian Longitudinal Study of Women's Health.

STUDY QUESTION: Do diet, physical activity and contraceptive use change after receiving a diagnosis of polycystic ovary syndrome (PCOS)? SUMMARY ANSWER: Using longitudinal data 12 months apart, young women newly diagnosed with PCOS were more likely to stop using contraception but did not change their physical activity or vegetable intake. WHAT IS KNOWN ALREADY: Diagnostic criteria for PCOS have widened to capture more women, despite limited evidence of the benefits and harms. Possible benefits of a PCOS diagnosis are that it may help women with family planning and motivate them to implement healthy lifestyle changes to reduce the reproductive, metabolic and cardiovascular risks associated with PCOS. However, there are no empirical studies investigating how women respond to a diagnosis of PCOS with respect to their health behaviour, and longitudinal population-based studies are lacking. STUDY DESIGN, SIZE, DURATION: This is a longitudinal analysis of two waves of data collected 12 months apart from the cohort born 1989-1995 in the Australian Longitudinal Survey on Women's Health, a population-based cohort study. Women in this cohort were first surveyed in 2012-2013, aged 18-23 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women who responded to the 2014 survey (aged 19-24, n = 11 344) and 2015 survey (aged 20-25, n = 8961) were included. Using logistic regression, multinomial logistic regression and linear regression, change in vegetable intake, physical activity and contraceptive use were compared for women newly diagnosed with PCOS to women not reporting a diagnosis of PCOS. Changes in psychological distress and BMI were also examined. MAIN RESULTS AND THE ROLE OF CHANCE: Young women reporting a new diagnosis of PCOS were no more likely to increase their vegetable intake or physical activity than women not reporting a PCOS diagnosis. Women newly diagnosed with PCOS were 3.4 times more likely to stop using contraception during the 12-month study period than women without PCOS (14% versus 4%, 95% CI = 2.3 to 5.1, P < 0.001). This difference remained significant after controlling for demographics, chronic conditions associated with PCOS, endometriosis, BMI and psychological distress (P < 0.001). LIMITATIONS, REASONS FOR CAUTION: All data was self-reported including PCOS diagnosis, assessment of diet quality was limited to vegetable intake only. The exact timing of diagnosis within the 12-month period and whether the women intended to conceive are unknown. The number of women reporting a new diagnosis of PCOS was also relatively small. WIDER IMPLICATIONS OF THE FINDINGS: These findings suggest that a diagnosis of PCOS may not produce short-term benefits by way of improving health behaviour. The observed reduction in contraception use suggests some women may be at increased risk of unplanned pregnancies, highlighting the importance of counselling about contraceptive needs. Both potential benefits and harms must be considered when determining the appropriateness of a PCOS diagnosis. STUDY FUNDING/COMPETING INTEREST(S): The Australian Longitudinal Study on Women's Health is funded by the Australian Government Department of Health. BWM reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist. TRIAL REGISTRATION NUMBER: N/A.

A review of changes to the attention deficit/hyperactivity disorder age of onset criterion using the checklist for modifying disease definitions.

BACKGROUND: Widening definitions of health conditions have the potential to affect millions of people and should only occur when there is strong evidence of benefit. In the last version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5 Committee changed the Attention Deficit Hyperactivity Disorder (ADHD) age of onset criterion in two ways: raising the age of symptom onset and removing the requirement for symptoms to cause impairment. Given concerns about ADHD prevalence and treatment rates, we aimed to evaluate the evidence available to support these changes using a recently developed Checklist for Modifying Disease Definitions. METHODS: We identified and analysed research informing changes to the DSM-IV-TR ADHD age of onset criterion. We compared this evidence to the evidence recommended in the Checklist for Modifying Disease Definitions. RESULTS: The changes to the DSM-IV-TR age of onset criterion were based on a literature review (publicly available as a 2 page document with online table of included studies), which we appraised as at high risk of bias. Estimates of the change in ADHD prevalence resulting from change to the age of onset criterion were based on a single study that included only a small number of children with ADHD (n = 68) and only assessed the impact of change to the age component of the criterion. No evidence was used by, or available to the Committee regarding the impact on prevalence of removal of the requirement for impairment, or the effect of the criterion changes on diagnostic precision, the prognosis of, or the potential benefits or harms for individuals diagnosed by the new, but not old criterion. CONCLUSIONS: The changes to the age of onset criterion were based on minimal research evidence that suffered from either high risk of bias or poor applicability. The minimal documentation available makes it difficult to judge the rigor of the process behind the criterion changes. Use of the Checklist for Modifying Disease Definitions would assist future proposed modifications of the DSM ADHD criteria, provide guidance on the studies needed to inform potential changes and would improve the transparency and documentation of the process.

An Australian community jury to consider case-finding for dementia: Differences between informed community preferences and general practice guidelines.

BACKGROUND: Case-finding for dementia is practised by general practitioners (GPs) in Australia but without an awareness of community preferences. We explored the values and preferences of informed community members around case-finding for dementia in Australian general practice. DESIGN, SETTING AND PARTICIPANTS: A before and after, mixed-methods study in Gold Coast, Australia, with ten community members aged 50-70. INTERVENTION: A 2-day citizen/community jury. Participants were informed by experts about dementia, the potential harms and benefits of case-finding, and ethical considerations. PRIMARY AND SECONDARY OUTCOMES: We asked participants, "Should the health system encourage GPs to practice 'case-finding' of dementia in people older than 50?" Case-finding was defined as a GP initiating testing for dementia when the patient is unaware of symptoms. We also assessed changes in participant comprehension/knowledge, attitudes towards dementia and participants' own intentions to undergo case-finding for dementia if it were suggested. RESULTS: Participants voted unanimously against case-finding for dementia, citing a lack of effective treatments, potential for harm to patients and potential financial incentives. However, they recognized that case-finding was currently practised by Australian GPs and recommended specific changes to the guidelines. Participants increased their comprehension/knowledge of dementia, their attitude towards case-finding became less positive, and their intentions to be tested themselves decreased. CONCLUSION: Once informed, community jury participants did not agree case-finding for dementia should be conducted by GPs. Yet their personal intentions to accept case-finding varied. If case-finding for dementia is recommended in the guidelines, then shared decision making is essential.

Evidence for overuse of medical services around the world.

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.