Sustainable oral healthcare: what is it and how do we achieve it?

In recent years, there has been an increase in interest in what environmental sustainability means for healthcare, including oral health and dentistry. To help facilitate discussions among key stakeholders in this area, the Scottish Dental Clinical Effectiveness Programme held a workshop in November 2022. The purpose of this workshop was to explore current thinking on the subject of sustainability as it relates to oral health and to help stakeholders identify how to engage with the sustainability agenda. This paper presents an overview of the presentations and discussions from the workshop and highlights potential avenues for future work and collaboration.

Telemedicine and the assessment of clinician time: a scoping review.

OBJECTIVES: Telemedicine may improve healthcare access and efficiency if it demands less clinician time than usual care. We sought to describe the degree to which telemedicine trials assess the effect of telemedicine on clinicians' time and to discuss how including the time needed to treat (TNT) in health technology assessment (HTA) could affect the design of telemedicine services and studies. METHODS: We conducted a scoping review by searching clinicaltrials.gov using the search term "telemedicine" and limiting results to randomized trials or observational studies registered between January 2012 and October 2023. We then reviewed trial registration data to determine if any of the outcomes assessed in the trials measured effect on clinicians' time. RESULTS: We found 113 studies and of these 78 studies of telemedicine met the inclusion criteria and were included. Nine (12 percent) of the 78 studies had some measure of clinician time as a primary outcome, and 11 (14 percent) as a secondary outcome. Four studies compared direct measures of TNT with telemedicine versus usual care, but no statistically significant difference was found. Of the sixteen studies including indirect measures of clinician time, thirteen found no significant effects, two found a statistically significant reduction, and one found a statistically significant increase. CONCLUSIONS: This scoping review found that clinician time is not commonly measured in studies of telemedicine interventions. Attention to telemedicine's TNT in clinical studies and HTAs of telemedicine in practice may bring attention to the organization of clinical workflows and increase the value of telemedicine.

[What is overdiagnosis?] / Överdiagnostik ­ vad är det?

A considerable amount of spending in health care is deemed wasteful. Overdiagnosis, i.e. the labelling of a person with a diagnosis that lacks net benefit, is an entity within the overarching concept of ¼too much medicine«. Overdiagnosis includes overdetection and overdefinition. Disease mongering is a type of overdefinition with economic drivers. Overtesting and overtreatment are other aspects of ¼too much medicine«, but are not overdiagnosis per se. Medical research tends to focus on benefits of diagnostics and therapy, whereas overdiagnosis and other harms receive less attention, leading to overestimation of benefits. The international network Choosing Wisely has been successful in changing the diagnostic mindset in several countries and a Swedish campaign is under way, yielding new possibilities to counteract ¼too much medicine« and the specific problem of overdiagnosis.

Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review.

OBJECTIVE: Overdiagnosis and overuse of healthcare services harm individuals, take resources that could be used to address underuse, and threaten the sustainability of health systems. These problems are attracting increasing attention in low-income and middle-income countries (LMICs). Unaware of any review of relevant evidence, we conducted a scoping review of the evidence around overdiagnosis and overuse of diagnostic and screening tests in LMICs. DESIGN: Scoping review. METHODS: We searched PubMed, Embase, PsycINFO, Global Index Medicus for relevant studies published until 24 May 2021, with no restrictions on date or language. We categorised included studies by major focus (overdiagnosis, overuse of tests, or both) and main themes (presence or estimates of extent; drivers; consequences and solutions). RESULTS: We identified 2763 unique records and included 162 articles reporting on 154 studies across 55 countries, involving over 2.8 million participants and/or requests for tests. Almost half the studies focused on overdiagnosis (70; 45.5%), one-third on overuse of tests (61; 39.6%) and one-fifth on both (23; 14.9%). Common overdiagnosed conditions included malaria (61; 39.6%) and thyroid cancer (25; 16.2%), estimated to be >70% in China. Overused tests included imaging (n=25 studies) such as CT and MRI; laboratory investigations (n=18) such as serological tests and tumour markers; and procedures (n=14) such as colonoscopy. Drivers included fear of conflict with patients and expanding disease definitions. Common consequences included unnecessary treatments such as antimalarials, and wasted resources, with costs of malaria overdiagnosis estimated at US$86 million in Sudan in 1 year alone. Only 9% of studies discussed solutions, which included addressing inappropriately lowered diagnostic thresholds and reforming test-ordering processes. CONCLUSIONS: Overdiagnosis and overuse of tests are widespread in LMICs and generate significant harm and waste. Better understanding of the problems and robust evaluation of solutions is needed, informed by a new global alliance of researchers and policy-makers.

Evaluation of evidence supporting NICE recommendations to change people's lifestyle in clinical practice: cross sectional survey.

Objectives: To assess whether recommendations of individually oriented lifestyle interventions (IOLIs) in guidelines from the National Institute for Health and Care Excellence (NICE) were underpinned by evidence of benefit, and whether harms and opportunity costs were considered. Design: Cross sectional survey. Setting: UK. Data sources: NICE guidelines and supporting evidence. Eligibility criteria: All NICE pathways for IOLI recommendations (ie, non-drug interventions that healthcare professionals administer to adults to achieve a healthier lifestyle and improve health) were searched systematically on 26 August 2020. One author screened all retrieved pathways for candidate guidelines, while a second author verified these judgments. Two authors independently and in duplicate screened all retrieved guidelines and recommendations for eligibility, extracted data, and evaluated the evidence cited and the outcomes considered. Disagreements were noted and resolved by consensus. Results: Within 57 guidelines, 379 NICE recommendations were found for IOLIs; almost all (n=374; 99%) recommended the lifestyle intervention and five (1%) recommended against the intervention. Of the 379 recommendations, 13 (3%) were supported by moderate or high certainty evidence of a beneficial effect on patient relevant outcomes (n=7; 2%) or surrogate outcomes (n=13; 3%). 19 (5%) interventions considered psychosocial harms, 32 (8%) considered physical harms, and one (<1%) considered the opportunity costs of implementation. No intervention considered the burden placed on individuals by these recommendations. Conclusion: Few NICE recommendations of lifestyle interventions are supported by reliable evidence. While this finding does not contest the beneficial effects of healthy habits, guidelines recommending clinicians to try to change people's lifestyle need to be reconsidered given the substantial uncertainty about the effectiveness, harms, and opportunity costs of such interventions.

Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review.

OBJECTIVES: To determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic. DESIGN: Systematic review. ELIGIBILITY: Eligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics and therapeutics. Studies were excluded if from single centres or studied only patients with COVID-19. DATA SOURCES: PubMed, Embase, Cochrane COVID-19 Study Register and preprints were searched, without language restrictions, until 10 August, using detailed searches with key concepts including COVID-19, health services and impact. DATA ANALYSIS: Risk of bias was assessed by adapting the Risk of Bias in Non-randomised Studies of Interventions tool, and a Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures and narrative synthesis. OUTCOME MEASURES: Primary outcome was change in service utilisation between prepandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (eg, triage scores). RESULTS: 3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services prepandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (IQR -51% to -20%), comprising median reductions for visits of 42% (-53% to -32%), admissions 28% (-40% to -17%), diagnostics 31% (-53% to -24%) and for therapeutics 30% (-57% to -19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27 (45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no difference. CONCLUSIONS: Healthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health systems reduce unnecessary care in the postpandemic recovery. PROSPERO REGISTRATION NUMBER: CRD42020203729.

Addressing harms of screening - A review of outcomes in Cochrane reviews and suggestions for next steps.

OBJECTIVE: To investigate if Cochrane reviews that assess screening interventions address their major harms. STUDY DESIGN AND SETTING: A systematic search for Cochrane reviews that assess screening interventions was performed. Two authors independently screened abstracts, assessed full-texts, and extracted data from included reviews. For each review, two authors judged whether each predefined harm was relevant. When the harm was judged as of questionable relevance, the review was excluded from the denominator in our calculations. RESULTS: Forty-seven reviews were included. Overdiagnosis was addressed in 6 of 39 (15%), overtreatment in 7 of 43 (16%), and psychosocial consequences in 30 of 47 (64%) of reviews where this was judged relevant. When data on harms were included, they were generally not treated with the same methodological rigor as the benefits, with no assessment of the risk of bias or certainty of the evidence. About half of the Abstracts, Plain Language Summaries, and Summary of Findings tables did not include any harms. CONCLUSION: The underreporting of harms of screening in Cochrane reviews likely reflects primary research and is problematic. We call for broad collaboration to develop reporting guidelines and core outcome sets for studies of screening interventions.

Confounding biases in studies on early- versus late-caffeine in preterm infants: a systematic review.

BACKGROUND: Caffeine is indicated for the management of apnoea of prematurity and extubation in preterm infants. Early initiation of caffeine administration has increased in the past decades with the purpose of reducing respiratory morbidity. However, there might be harms associated with this approach. This systematic review aims to assess whether early administration of caffeine reduces morbidity and mortality in preterm infants. METHODS: The methods were published in a preregistered protocol. The literature search was performed in February 2019 with no restrictions for language or publication date. Randomised controlled trials (RCTs) and cohort studies comparing early versus late caffeine administration to infants born before week 34 were included. RESULTS: Two RCTs and 14 cohort studies were included. All studies but one had a serious/critical overall risk of bias. Few studies reported on long-term or patient-relevant outcomes. No meta-analysis could be performed. CONCLUSION: Based on the available evidence, no conclusions about the optimal timing of caffeine administration can be drawn. There are inherent methodological problems in the cohort studies. RCTs are needed to answer the question of optimal timing for caffeine administration in neonatal care. Future trials should focus on outcomes relevant to patients and their families and include long-term outcomes.