[High prevalence of treatment with ADHD medicines indicates overdiagnosis of ADHD in Iceland].

INTRODUCTION: ADHD is a neurodevelopmental disorder characterized by hyperactivity, inattention and impulsivity. For many the core symptoms become less troubling in adulthood. Treatment with stimulants is considered the most efficacious treatment for ADHD. Large high-quality studies have estimated the prevalence of AHDH to be 3,4-7,2% for children and adolescents and 2,5-6,8% for young adults. The aim of this study was to estimate the proportion of Icelanders who have received an ADHD diagnosis based on ADHD-medication prescriptions since an ADHD diagnosis is a prerequisite for such prescriptions in Iceland. METHODS: This population-based retrospective cohort study included all Icelanders 7-70 years old who received a prescription for an ADHD drug from 1.1.2004-31.12.2023. Every citizen receiving a prescription is included in the Icelandic Prescription Medicines Registry (IPMR). RESULTS: In 2023 14,7% of youth, 7-17 years of age, received a prescription for an ADHD medication, 17,7% of boys and 11,6% of girls. Among 12-17 years old youth the proportion was higher still, 17,6%, 20,1% for boys and 14,6% for girls. For 18-44 years old adults the proportion was 10,2%, 9,4% for males and 11,0% for females. From 2010-2023 the increase in prescriptions for 7-17 years old boys has been 93% but 224% for girls. For 18-44 years old males the increase has been 414% for males and 543% for females during this period. The incidence of new ADHD prescriptions for 7-17 years old boys from 2021-2023 was 10,9 and 13,5 for girls per 1000, respectively. For 18-44 years old the incidence in the years 2021-2023 was 18,7 for males and 19,2 for females per 1000, respectively. CONCLUSION: The prevalence of Icelanders who have received an ADHD diagnosis is double to treble that observed in the best available studies in other populations. We therefore call for an urgent review of how ADHD diagnoses are made in Iceland because it is obvious that the current system leads to overdiagnosis and inappropriate treatment.

Impact of point-of-care gonorrhea and chlamydia testing in the emergency department on reducing overtreatment rates.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections continue to increase in the United States. Advancement in technology with point-of-care (POC) testing can improve the overall treatment of sexually transmitted infections (STI) in the emergency department (ED) by shortening the time to test result and administration of accurate treatment. The purpose of this study was to assess if the POC test reduced the rate of overtreatment for CT and/or NG compared to the standard-of-care (SOC) test. METHODS: This retrospective cohort study included adult patients tested for CT and NG at two urban EDs between August 2020 and October 2022. This cohort excluded hospital admissions, elopement, pregnancy, rectal and oral samples, victims of sexual assault, and diagnoses for which antimicrobial treatment overlapped that of CT/NG. The primary outcome assessed overtreatment, defined as receiving treatment in the ED or a prescription prior to discharge for patients who tested negative for CT and/or NG. Secondary outcomes included undertreatment rates, overtreatment rates in select populations, test turnaround time, and ED length of stay (LOS). RESULTS: Of 327 patients screened, 97 patients were included in the SOC group and 100 in POC. Overtreatment for CT was provided in zero POC patients and 29 (29.9%) SOC patients (p < 0.001). NG was overtreated in 1 (1%) POC and 23 (23.7%) SOC (p < 0.001). POC was associated with undertreatment of CT and/or NG in two patients, compared to four patients tested with SOC. Overall, treatment was deemed inappropriate for 5 (5%) of those tested with POC, compared to 35 (36%) tested with SOC (p < 0.001). There was no difference in ED LOS (2.7 vs 3.01 h, p = 0.41). CONCLUSIONS: POC testing facilitated the return of results prior to patients being discharged from the ED. Compared to standard testing, POC improved appropriateness of CT and NG treatment by reducing the rates of overtreatment.

Ordinary defensive medicine: in the shadows of general practitioners' postures toward (over-)medicalisation.

This paper draws on qualitative research using focus groups involving 38 general practitioners (GPs). It explores their attitudes and feelings about (over-)medicalisation. Our main findings were that GPs had a complex representation of (over-)medicalisation, composed of many professional, social, technological, economic and relational issues. This representation led GPs to feel uncomfortable. They felt pressure from all sides, which led them to question their social roles and responsibilities. We identified four main GP-driven proposals to deal with (over-)medicalisation: (1) focusing on the communication in doctor-patient relationships; (2) grounding practices in evidence-based medicine; (3) relying on clinical skills, experience and intuition; and (4) promoting training, leadership bodies and social movements. Drawing on these proposals, we identify and discuss five paradigms that underpin GPs' attitudes toward (over-)medicalisation: underlying social factors, preventing medicalisation, managing uncertainties, sharing medical decision-making and thinking about care as a rationale. We suggest that these paradigms constitute a defensive posture against GPs' uncomfortable feelings. All five defensive paradigms were identified in our focus groups, echoing contemporary political debates on public health. This non-exhaustive framework forms the outline of what we call ordinary defensive medicine. GPs' uncomfortable feelings are the origin of their defensive solutions and the manifestation of their vulnerability. This professional vulnerability can be shared with the patient's vulnerability. In our view, this creates an opportunity to rediscover patient-doctor relationships and examine patients' and doctors' vulnerabilities together."There are many cases in which-though the signs of a confusion of tongues between the patient and his doctor are painfully present-there is apparently no open controversy. Some of these cases demonstrate the working of two other, often interlinked, factors. One is the patient's increasing anxiety and despair, resulting in more and more fervently clamouring demands for help. Often the doctor's response is guilt feelings and despair that his most conscientious, most carefully devised examinations do not seem to throw real light on the patient's "illness", that his most erudite, most modern, most circumspect therapy does not bring real relief." (Balint M. The Doctor, His Patient and the Illness. New York: International Universities; 2005. [1957].)"Theories about care put an unprecedented emphasis on vulnerability-taking up that challenge to transform what really counts in today's hospitals implies letting colleagues inside previously closely guarded professional boundaries" (2, our translation).

'The health care system is more like a business'-medical overuse from the patients' perspective in Germany: a qualitative study.

OBJECTIVES: Medical overuse exposes patients to unnecessary risks of harm. It is an open question whether and how patients perceive the concept of medical overuse, its causes and negative consequences. DESIGN: A qualitative study design, using elements of the Grounded Theory Approach by Strauss and Corbin. SETTING: Between May 2017 and January 2020, we recruited participants and conducted face-to-face interviews in the participants' homes. Data collection took place in Bavaria, Germany. PARTICIPANTS: We recruited 16 participants (female=8, male=8) with various characteristics for the study. We used different strategies such as flyers in supermarkets, pharmacies, participants spreading information about the study or local multipliers (snowball sampling). RESULTS: The participants mostly defined medical overuse as too much being done but understood the concept superficially. During the interviews, most participants could describe examples of medical overuse. They named a variety of direct and indirect drivers with economic factors suspected to be the main driver. As a consequence of medical overuse, participants named the physical and emotional harm (eg, side effects of medication). They found it difficult to formulate concrete solutions. In general, they saw themselves more in a passive role than being responsible for bringing about change and solutions themselves. Medical overuse is a 'problem of the others'. The participants emphasised that health education is important in reducing medical overuse. CONCLUSIONS: Medical overuse was little discussed among participants, although many participants reported experiences of too much medicine. Health education and strengthening the patients' self-responsibility can play a vital role in reducing medical overuse.

USPSTF Recommendations and Overdiagnosis.

Overdiagnosis is the concept that some cancers detected at screening would never have become clinically apparent during a woman's lifetime in the absence of screening. This could occur if a woman dies of a cause other than breast cancer in the interval between mammographic detection and clinical detection (obligate overdiagnosis) or if a mammographically detected breast cancer fails to progress to clinical presentation. Overdiagnosis cannot be measured directly. Indirect methods of estimating overdiagnosis include use of data from randomized controlled trials (RCTs) designed to evaluate breast cancer mortality, population-based screening studies, or modeling. In each case, estimates of overdiagnosis must consider lead time, breast cancer incidence trends in the absence of screening, and accurate and predictable rates of tumor progression. Failure to do so has led to widely varying estimates of overdiagnosis. The U.S. Preventive Services Task Force (USPSTF) considers overdiagnosis a major harm of mammography screening. Their 2024 report estimated overdiagnosis using summary evaluations of 3 RCTs that did not provide screening to their control groups at the end of the screening period, along with Cancer Intervention and Surveillance Network modeling. However, there are major flaws in their evidence sources and modeling estimates, limiting the USPSTF assessment. The most plausible estimates remain those based on observational studies that suggest overdiagnosis in breast cancer screening is 10% or less and can be attributed primarily to obligate overdiagnosis and nonprogressive ductal carcinoma in situ.

Identification of low-value practices susceptible to gender bias in primary care setting.

BACKGROUND: Data on overuse of diagnostic and therapeutic resources underline their contribution to the decline in healthcare quality. The application of "Do Not Do" recommendations, in interaction with gender biases in primary care, remains to be fully understood. Therefore, this study aims to identify which low-value practices (LVPs) causing adverse events are susceptible to be applied in primary care setting with different frequency between men and women. METHODS: A consensus study was conducted between November 1, 2021, and July 4, 2022, in the primary care setting of the Valencian Community, Spain. Thirty-three of the 61 (54.1%) health professionals from clinical and research settings invited, completed the questionnaire. Participants were recruited by snowball sampling through two scientific societies, meeting specific inclusion criteria: over 10 years of professional experience and a minimum of 7 years focused on health studies from a gender perspective. An initial round using a questionnaire comprising 40 LVPs to assess consensus on their frequency in primary care, potential to cause serious adverse events, and different frequency between men and women possibly due to gender bias. A second round-questionnaire was administered to confirm the final selection of LVPs. RESULTS: This study identified nineteen LVPs potentially linked to serious adverse events with varying frequencies between men and women in primary care. Among the most gender-biased and harmful LVPs were the use of benzodiazepines for insomnia, delirium, and agitation in the elderly, and the use of hypnotics without a previous etiological diagnosis. CONCLUSIONS: Identifying specific practices with potential gender biases, mainly in mental health for the elderly, contributes to healthcare promotion and bridges the gap in gender inequalities. TRIAL REGISTRATION: NCT05233852, registered on 10 February 2022.

Social Media Promotion of Health Tests With Potential for Overdiagnosis or Overuse: Protocol for a Content Analysis.

BACKGROUND: In recent years, social media have emerged as important spaces for commercial marketing of health tests, which can be used for the screening and diagnosis of otherwise generally healthy people. However, little is known about how health tests are promoted on social media, whether the information provided is accurate and balanced, and if there is transparency around conflicts of interest. OBJECTIVE: This study aims to understand and quantify how social media is being used to discuss or promote health tests with the potential for overdiagnosis or overuse to generally healthy people. METHODS: Content analysis of social media posts on the anti-Mullerian hormone test, whole-body magnetic resonance imaging scan, multicancer early detection, testosterone test, and gut microbe test from influential international social media accounts on Instagram and TikTok. The 5 tests have been identified as having the following criteria: (1) there are evidence-based concerns about overdiagnosis or overuse, (2) there is evidence or concerns that the results of tests do not lead to improved health outcomes for generally healthy people and may cause harm or waste, and (3) the tests are being promoted on social media to generally healthy people. English language text-only posts, images, infographics, articles, recorded videos including reels, and audio-only posts are included. Posts from accounts with <1000 followers as well as stories, live videos, and non-English posts are excluded. Using keywords related to the test, the top posts were searched and screened until there were 100 eligible posts from each platform for each test (total of 1000 posts). Data from the caption, video, and on-screen text are being summarized and extracted into a Microsoft Excel (Microsoft Corporation) spreadsheet and included in the analysis. The analysis will take a combined inductive approach when generating key themes and a deductive approach using a prespecified framework. Quantitative data will be analyzed in Stata SE (version 18.0; Stata Corp). RESULTS: Data on Instagram and TikTok have been searched and screened. Analysis has now commenced. The findings will be disseminated via publications in peer-reviewed international medical journals and will also be presented at national and international conferences in late 2024 and 2025. CONCLUSIONS: This study will contribute to the limited evidence base on the nature of the relationship between social media and the problems of overdiagnosis and overuse of health care services. This understanding is essential to develop strategies to mitigate potential harm and plan solutions, with the aim of helping to protect members of the public from being marketed low-value tests, becoming patients unnecessarily, and taking resources away from genuine needs within the health system. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56899.

Perspectives on low-value care and barriers to de-implementation among primary care physicians: a multinational survey.

BACKGROUND: Healthcare costs are rising worldwide. At the same time, a considerable proportion of care does not benefit or may even be harmful to patients. We aimed to explore attitudes towards low-value care and identify the most important barriers to the de-implementation of low-value care use in primary care in high-income countries. METHODS: Between May and June 2022, we email surveyed primary care physicians in six high-income countries (Austria, Finland, Greece, Italy, Japan, and Sweden). Physician respondents were eligible if they had worked in primary care during the previous 24 months. The survey included four sections with categorized questions on (1) background information, (2) familiarity with Choosing Wisely recommendations, (3) attitudes towards overdiagnosis and overtreatment, and (4) barriers to de-implementation, as well as a section with open-ended questions on interventions and possible facilitators for de-implementation. We used descriptive statistics to present the results. RESULTS: Of the 16,935 primary care physicians, 1,731 answered (response rate 10.2%), 1,505 had worked in primary care practice in the last 24 months and were included in the analysis. Of the respondents, 53% had read Choosing Wisely recommendations. Of the respondents, 52% perceived overdiagnosis and 50% overtreatment as at least a problem to some extent in their own practice. Corresponding figures were 85% and 81% when they were asked regarding their country's healthcare. Respondents considered patient expectations (85% answered either moderate or major importance), patient's requests for treatments and tests (83%), fear of medical error (81%), workload/lack of time (81%), and fear of underdiagnosis or undertreatment (79%) as the most important barriers for de-implementation. Attitudes and perceptions of barriers differed significantly between countries. CONCLUSIONS: More than 80% of primary care physicians consider overtreatment and overdiagnosis as a problem in their country's healthcare but fewer (around 50%) in their own practice. Lack of time, fear of error, and patient pressures are common barriers to de-implementation in high-income countries and should be acknowledged when planning future healthcare. Due to the wide variety of barriers to de-implementation and differences in their importance in different contexts, understanding local barriers is crucial when planning de-implementation strategies.

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.

Imaging overuse in the emergency department: The view of radiologists and emergency physicians.

PURPOSE: To identify the perceived factors contributing to imaging overuse in the emergency department, according to radiologists and emergency physicians. METHOD: A survey study on imaging overuse in the emergency department was conducted among 66 radiologists and 425 emergency physicians. Five-point Likert scales (not a problem at all/strongly disagree [score 1] to very serious problem/strongly agree [score 5]) were used to score the various aspects of overimaging. RESULTS: Both radiologists and emergency physicians gave a median score of 4 to the question if imaging overuse is a problem in their emergency department. CT accounts for the vast majority of imaging overuse, according to both radiologists (84.8%) and emergency physicians (75.3%). Defensive medicine/fear of malpractice, the presence of less experienced staff, and easy access to imaging all were given a median score of 4 as factors that influence imaging overuse, by both physician groups. Median ratings regarding the influence of pressure from patients and a lack of time to examine patients on imaging overuse varied between 3 and 4 for radiologists and emergency physicians. Pressure from consultants to perform imaging, the use of imaging to decrease turnaround time in the emergency department, a lack of space in the emergency department, a lack of proper medical education, and inability to access outside imaging studies, were also indicated to give rise to imaging overuse. CONCLUSIONS: Imaging overuse in the emergency department (particularly CT overuse) is a problem according to most radiologists and emergency physicians, and is driven by several factors.

Understanding provider use of a new clinical decision support tool aimed at reducing excess telemetry in an academic health system: A retrospective study.

RATIONALE: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. AIMS AND OBJECTIVES: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. METHODS: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. RESULTS: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%-57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. CONCLUSION: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication.

[Medical overuse, defensive medicine and new reform of professional mistake].

Reflecting on the inappropriateness (medical overuse) and on defensive medicine, the Authors wonder whether the new Italian reform of professional guilt, desired at all institutional levels, will actually contain the high economic costs produced by these large and widespread phenomena. After having characterized the medical overuse and the defensive medicine indicating the common traits and main differences, the reflection is conducted by exploring the many scientific evidence that does not document any causal link between the decriminalization of professional conduct and the containment of the costs produced by the prescriptive inappropriateness. They conclude by stating that, for their containment, a third reform of professional liability will not be helpful. Instead, it must focus on other issues, mainly addressing the excessive reliance on judicial recourse. It should provide for mandatory out-of-court conciliatory mechanisms and clarifying the protective umbrella of the doctor's non-criminality.

[The overdiagnosis of thyroid cancer should not be overinterpreted].

Recently, the topic of "overdiagnosis" of thyroid cancer has once again sparked controversy in the medical academic community, as well as extensive discussions from patients and the general population. To some extent, the overdiagnosis of thyroid cancer has been over interpreted. This article provides a detailed discussion on how to correctly understand the overdiagnosis of thyroid cancer from the perspective of a thyroid surgeon. The author believes that there are two elements to the occurrence of overdiagnosis of thyroid cancer: the presence of a large "silent pool" of inert tumors in the human body and medical methods to improve detection rates. In recent years, thyroid cancer has become the fastest growing malignant tumor in the world in terms of incidence rate. The exponential growth mode makes thyroid cancer over diagnosed and inevitably becomes a hot topic in academia. However, the overdiagnosis of thyroid cancer is not contradictory to the early screening and diagnosis of thyroid cancer. The overdiagnosis of thyroid cancer should be viewed scientifically and rationally, especially avoiding overinterpretation.

Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme.

Utilisation rates for healthcare services vary widely both within and between nations. Moreover, healthcare providers with insurance-based reimbursement systems observe an effect of social determinants of health on healthcare utilisation rates and outcomes. Even in countries with publicly funded universal healthcare such as Norway, utilisation rates for medical and surgical interventions vary between and within health regions and hospitals.Most interventions targeting overuse and high utilisation rates are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation. Recommendations regarding how to reduce this variation are often not very detailed or prominent.This paper describes a protocol for reducing the overuse of upper endoscopy in a Norwegian health region. The protocol uses a combination of digital tools and psychological methods targeting behavioural change in order to alter healthcare workers' approach to patient care.The aim of the planned intervention is to evaluate the effectiveness of a multifaceted set of interventions to reduce the overuse of upper endoscopy in patients under 45 years. A secondary aim is to evaluate the specific effect of the various parts of the intervention.

Is Myocardial Infarction Overdiagnosed?

This Viewpoint examines whether overdiagnosis rather than underdiagnosis may now be the dominant form of myocardial infarction misdiagnosis.

Collaborative Modeling to Compare Different Breast Cancer Screening Strategies: A Decision Analysis for the US Preventive Services Task Force.

Importance: The effects of breast cancer incidence changes and advances in screening and treatment on outcomes of different screening strategies are not well known. Objective: To estimate outcomes of various mammography screening strategies. Design, Setting, and Population: Comparison of outcomes using 6 Cancer Intervention and Surveillance Modeling Network (CISNET) models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses. Exposures: Thirty-six screening strategies with varying start ages (40, 45, 50 years) and stop ages (74, 79 years) with digital mammography or digital breast tomosynthesis (DBT) annually, biennially, or a combination of intervals. Strategies were evaluated for all women and for Black women, assuming 100% screening adherence and "real-world" treatment. Main Outcomes and Measures: Estimated lifetime benefits (breast cancer deaths averted, percent reduction in breast cancer mortality, life-years gained), harms (false-positive recalls, benign biopsies, overdiagnosis), and number of mammograms per 1000 women. Results: Biennial screening with DBT starting at age 40, 45, or 50 years until age 74 years averted a median of 8.2, 7.5, or 6.7 breast cancer deaths per 1000 women screened, respectively, vs no screening. Biennial DBT screening at age 40 to 74 years (vs no screening) was associated with a 30.0% breast cancer mortality reduction, 1376 false-positive recalls, and 14 overdiagnosed cases per 1000 women screened. Digital mammography screening benefits were similar to those for DBT but had more false-positive recalls. Annual screening increased benefits but resulted in more false-positive recalls and overdiagnosed cases. Benefit-to-harm ratios of continuing screening until age 79 years were similar or superior to stopping at age 74. In all strategies, women with higher-than-average breast cancer risk, higher breast density, and lower comorbidity level experienced greater screening benefits than other groups. Annual screening of Black women from age 40 to 49 years with biennial screening thereafter reduced breast cancer mortality disparities while maintaining similar benefit-to-harm trade-offs as for all women. Conclusions: This modeling analysis suggests that biennial mammography screening starting at age 40 years reduces breast cancer mortality and increases life-years gained per mammogram. More intensive screening for women with greater risk of breast cancer diagnosis or death can maintain similar benefit-to-harm trade-offs and reduce mortality disparities.