Trends in thyroid function testing, neck ultrasound, thyroid fine needle aspiration, and thyroidectomies in North-eastern Italy.

PURPOSE: Evidence of an increased diagnostic pressure on thyroid has emerged over the past decades. This study aimed to provide estimates of a wide spectrum of surveillance indicators for thyroid dysfunctions and diseases in Italy. METHODS: A population-based study was conducted in North-eastern Italy, including 11.7 million residents (20% of the total Italian population). Prescriptions for TSH testing, neck ultrasound or thyroid fine needle aspiration (FNA), surgical procedures, and drugs for hypo- or hyperthyroidism were extracted from regional health databases. Proportions and rates of selected examinations were calculated from 2010 to 2017, overall and by sex, calendar years, age, and region. RESULTS: Between 2010 and 2017 in North-eastern Italy, 24.5% of women and 9.8% of men received at least one TSH test yearly. In 2017, 7.1% of women and 1.5% of men were prescribed drugs for thyroid dysfunction, 94.6% of whom for hypothyroidism. Neck ultrasound examinations were performed yearly in 6.9% of women and 4.6% of men, with a nearly two-fold variation between areas. Thyroid FNA and thyroidectomies were three-fold more frequent in women (394 and 85 per 100,000) than in men (128 and 29 per 100,000) with a marked variation between areas. Both procedures decreased consistently after 2013. CONCLUSIONS: The results of this population-based study describe recent variations over time and between surrounding areas of indicators of 'diagnostic pressure' on thyroid in North-eastern Italy. These results emphasize the need to harmonize practices and to reduce some procedures (e.g., neck ultrasound and total thyroidectomies) in certain areas.

Practice Patterns of Vascular Surgery's "1%".

BACKGROUND: Public focus on health care spending has increased attention on variation in practice patterns and overutilization of high-cost services. Mainstream news reports have revealed that a small number of providers account for a disproportionate amount of total Medicare payments. Here, we explore variation in Medicare payments among vascular surgeons and compare practice patterns of the most highly reimbursed surgeons to the rest of the workforce. METHODS: 2016 Medicare Provider Utilization Data were queried to identify procedure, charge, and payment data to vascular surgeons, identified by National Provider Identification taxonomy. Commonly performed services (>10/year) were stratified into categories (endovascular, open surgery, varicose vein, evaluation and management, etc.). Practice patterns of vascular surgeons comprising the top 1% Medicare payments (n = 31) were compared with the remainder of the workforce (n = 3,104). RESULTS: In 2016, Medicare payments to vascular surgeons totaled $589 M. 31 vascular surgeons-1% of the workforce-received $91 million (15% of total payments). Practice patterns of the 1% differed significantly from the remainder of vascular surgeons (P < 0.05), with endovascular procedures accounting for 85% of their reimbursement. Specifically, the 1% received 49% of total Medicare payments for atherectomy ($121 M), 98% of which were performed in the office setting. CONCLUSIONS: One percentage of vascular surgeons receive an inordinate amount of total Medicare payments to the specialty. This discrepancy is due to variations in volume, utilization, and site of service. Disproportionate use of outpatient atherectomy in a small number of providers, for example, raises concerns regarding appropriateness and overutilization. Given current scrutiny over health care spending, these findings should prompt serious discussion regarding the utility of personal and societal self-regulation.

The impact of the COVID-19 pandemic and governor mandated stay at home order on emergency department super utilizers.

BACKGROUND: Despite the trend of rising Emergency Department (ED) visits over the past decade, researchers have observed drastic declines in number of ED visits due to the COVID-19 pandemic. The purpose of the current study was to examine the impact of the COVID-19 pandemic and governor mandated Stay at Home Order on ED super utilizers. METHODS: This was a retrospective chart review of patients presenting to the 12 emergency departments of the Franciscan Mission of Our Lady Hospital System in Louisiana between January 1, 2018 and December 31, 2020. Patients who were 18 years of age or older and had four ED visits within a one-year period (2018, 2019, or 2020) were classified as super-utilizers. We examined number and category of visits for the baseline period (January 2018 - March 2020), the governor's Stay at Home Order, and the subsequent Reopening Phases through December 31, 2020. RESULTS: The number of visits by super utilizers decreased by over 16% when the Stay at Home Order was issued. The average number of visits per week rose from 1010.63 during the Stay at Home Order to 1198.09 after the Stay at Home Order was lifted, but they did not return to Pre-COVID levels of approximately 1400 visits per week in 2018 and 2019. When categories of visits were examined, this trend was found for emergent visits (p < 0.001) and visits related to injuries (p < 0.001). Non-emergent visits declined during the Stay at Home Order compared to the baseline period (p < 0.001), and did not increase significantly during reopening compared to the Stay at Home Order (p = 0.87). There were no changes in number of visits for psychiatric purposes, alcohol use, or drug use during the pandemic. CONCLUSIONS: Significant declines in emergent visits raise concerns that individuals who needed ED treatment did not seek it due to COVID-19. However, the finding that super utilizers with non-emergent visits continued to visit the ED less after the Stay at Home Order was lifted raises questions for future research that may inform policy and interventions for inappropriate ED use.

Technologies to address antimicrobial resistance.

Bacterial infections have been traditionally controlled by antibiotics and vaccines, and these approaches have greatly improved health and longevity. However, multiple stakeholders are declaring that the lack of new interventions is putting our ability to prevent and treat bacterial infections at risk. Vaccine and antibiotic approaches still have the potential to address this threat. Innovative vaccine technologies, such as reverse vaccinology, novel adjuvants, and rationally designed bacterial outer membrane vesicles, together with progress in polysaccharide conjugation and antigen design, have the potential to boost the development of vaccines targeting several classes of multidrug-resistant bacteria. Furthermore, new approaches to deliver small-molecule antibacterials into bacteria, such as hijacking active uptake pathways and potentiator approaches, along with a focus on alternative modalities, such as targeting host factors, blocking bacterial virulence factors, monoclonal antibodies, and microbiome interventions, all have potential. Both vaccines and antibacterial approaches are needed to tackle the global challenge of antimicrobial resistance (AMR), and both areas have the underpinning science to address this need. However, a concerted research agenda and rethinking of the value society puts on interventions that save lives, by preventing or treating life-threatening bacterial infections, are needed to bring these ideas to fruition.

Risk stratification in breast cancer screening: Cost-effectiveness and harm-benefit ratios for low-risk and high-risk women.

In mammography screening programmes, women are screened according to a one-size-fits-all principle. Tailored screening, based on risk levels, may lead to a better balance of benefits and harms. With microsimulation modelling, we determined optimal mammography screening strategies for women at lower (relative risk [RR] 0.75) and higher (RR 1.8) than average risk of breast cancer, eligible for screening, using the incremental cost-effectiveness ratio (ICER) of current uniform screening in the Netherlands (biennial [B] 50-74) as a threshold ICER. Strategies varied by interval (annual [A], biennial, triennial [T]) and age range. The number of life-years gained (LYG), breast cancer deaths averted, overdiagnosed cases, false-positive mammograms, ICERs and harm-benefit ratios were calculated. Optimal risk-based screening scenarios, below the threshold ICER of €8883/LYG, were T50-71 (€7840/LYG) for low-risk and B40-74 (€6062/LYG) for high-risk women. T50-71 screening in low-risk women resulted in a 33% reduction in false-positive findings, a similar reduction in costs and improved harm-benefit ratios compared to the current screening schedule. B40-74 in high-risk women led to an increase in screening benefit, compared to current B50-74 screening, but a relatively higher increase in false-positive findings. In conclusion, optimal screening consisted of a longer interval and lower stopping age than current uniform screening for low-risk women, and a lower starting age for high-risk women. Extending the interval for women at lower risk from biennial to triennial screening reduced harms and costs while maintaining most of the screening benefit.

Trends in Surgical Axillary Management in Early Stage Breast Cancer in Elderly Women: Continued Over-Treatment.

INTRODUCTION: In the past two decades, three prospective randomized trials demonstrated that elderly women with early stage hormone positive breast cancer had equivalent disease-specific mortality regardless of axillary surgery. In 2016, the Choosing Wisely campaign encouraged patients and providers to reconsider the role of axillary surgery in this population. We sought to identify factors that contribute to adopting non-operative management of the axilla in these patients. MATERIALS AND METHODS: We performed a retrospective analysis of women ≥ 70 years old with cT1/T2, hormone positive invasive ductal carcinoma who underwent partial or total mastectomy, with/without axillary surgery, and did not receive adjuvant chemotherapy from the National Cancer Database from 2004 to 2015. We used multivariable log-binomial regression to model the risk of undergoing axillary surgery across region, care setting, and Charlson-Deyo scores, and analyzed temporal trends using Poisson regression. From 2004 to 2015, 87,342 of 99,940 women who met inclusion criteria (83%) had axillary surgery. Over time, axillary surgery increased from 78% to 88% (p < 0.001). This rise was consistent across region (p = 0.81) and care setting (p = 0.09), but flattened as age increased (p < 0.001). Omitting axillary surgery was more likely in patients treated in New England (RR 0.88, 95% CI 0.86, 0.89) and patients ≥ 85 (RR 0.66, 95% CI 0.65, 0.67). CONCLUSIONS: Axillary surgery continues to be the preferred option of axillary management in elderly women with early stage, clinically node negative, hormone-positive, invasive breast cancer despite no survival benefit. Identifying factors to improve patient selection and dissemination of current recommendations can improve adoption of current evidence on axillary surgery in the elderly.

Race and socioeconomic differences associated with endovascular peripheral vascular interventions for newly diagnosed claudication.

BACKGROUND: Despite guidelines cautioning against the use of endovascular peripheral vascular interventions (PVI) for claudication, more than 1.3 million PVI procedures are performed annually in the United States. We aimed to describe national rates of PVI for claudication, and identify patient and county-level risk factors associated with a high rate of PVI. METHODS: We used the Medicare claims database to identify all Medicare beneficiaries with a new diagnosis of claudication between January 2015 and June 2017. A hierarchical logistic regression model accounting for patient age, sex, comorbidities; county region and setting; and a patient race-county median income interaction was used to assess the associations of race and income with a high PVI rate. RESULTS: We identified 1,201,234 patients with a new diagnosis of claudication for analysis. Of these, 15,227 (1.27%) underwent a PVI. Based on hierarchical logistic regression accounting for patient and county-level factors, black patients residing in low-income counties had a significantly higher odds of undergoing PVI than their white counterparts (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.20-1.40), whereas the odds of PVI for black versus white patients was similar in high-income counties (OR, 1.06; 95% CI, 0.99-1.14). PVI rates were higher for low versus high-income counties in both the black (OR, 1.46; 95% CI, 1.31-1.64) and white (OR, 1.19; 95% CI, 1.12-1.27) groups. There were no significant associations of Hispanic, Asian, North American native, or other races with PVI in either low- or high-income counties after risk adjustment (all P ≥ .09). CONCLUSIONS: In the Medicare population, the mean rate of PVI of 12.7 per 1000 claudication patients varies significantly based on race and income. Our data suggest there are racial and socioeconomic differences in the treatment of claudication across the United States.

Potentially Preventable Hospitalizations Among Older Adults: 2010-2014.

PURPOSE: We undertook a study to examine national trends in potentially preventable hospitalizations-those for ambulatory care-sensitive conditions that could have been avoided if patients had timely access to primary care-across 3,200 counties and various subpopulations of older adults in the United States. METHODS: We used 2010-2014 Medicare claims data to examine trends in potentially preventable hospitalizations among beneficiaries aged 65 years and older and developed heat maps to examine county-level variation. We used a generalized estimating equation and adjusted the model for demographics, comorbidities, dual eligibility (Medicare and Medicaid), ZIP code-level income, and county-level number of primary care physicians and hospitals. RESULTS: Across the 3,200 study counties, potentially preventable hospitalizations decreased in 327 counties, increased in 123 counties, and did not change in the rest. At the population level, the adjusted rate of potentially preventable hospitalizations declined by 3.45 percentage points from 19.42% (95% CI, 18.4%-20.5%) in 2010 to 15.97% (95% CI, 15.3%-16.6%) in 2014; it declined by 2.93, 2.87, and 3.33 percentage points among White, Black, and Hispanic patients to 14.96% (95% CI, 14.67%-15.24%), 17.92% (95% CI, 17.27%-18.58%), and 17.10% (95% CI, 16.25%-18.0%), respectively. Similarly, the rate for dually eligible patients fell by 3.71 percentage points from 21.62% (95% CI, 20.5%-22.8%) in 2010 to 17.91% (95% CI, 17.2%-18.7%) in 2014. (P <.001 for all). CONCLUSIONS: During 2010-2014, rates of potentially preventable hospitalization did not change in the majority of counties. At the population level, although the rate declined among all subpopulations, dually eligible patients and Black and Hispanic patients continued to have substantially higher rates compared with non-dually eligible and White patients, respectively.

How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years.

OBJECTIVES: To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion. DATA SOURCES: Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system. RESULTS: 45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors. SUMMARY/CONCLUSION: One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns. TRIAL REGISTRATION NUMBER: CRD42016041987.

Personalized Risks of Over Diagnosis for Screen Detected Prostate Cancer Incorporating Patient Comorbidities: Estimation and Communication.

PURPOSE: Shared patient-physician decision making regarding the treatment of prostate cancer detected by prostate specific antigen screening involves a complex calculus weighing cancer risk and patient life expectancy. We sought to quantify these competing risks using the probability that the cancer was over diagnosed, ie would not have been clinically diagnosed (diagnosed without screening) during the remaining lifetime of the patient. MATERIALS AND METHODS: Using an established model of prostate cancer screening and clinical diagnosis we simulated screen detected cases and determined whether a modeled clinical diagnosis would occur before noncancer death. Time of noncancer death was based on comorbidity adjusted population lifetables. Logistic regression models were fitted to the simulated data and used to estimate over diagnosis probabilities given patient age, prostate specific antigen level, Gleason sum and comorbidity category. An online calculator was developed to communicate over diagnosis estimates. Face validity and ease of use were assessed by surveying 32 clinical experts. RESULTS: Estimated probabilities of over diagnosis ranged from 4% to 78% across clinicopathological variables and comorbidity status. When ignoring comorbidity, the estimated probability of over diagnosis in a 70-year-old man with prostate specific antigen 9.4 ng/ml and Gleason 6 was 34%. With severe comorbidities the estimate increased to 51%. Such a personalization may help inform the choice between active surveillance and definitive treatment. Based on responses from 20 of 32 experts we modified the explanation of over diagnosis for the online calculator and the input method for comorbid conditions. CONCLUSIONS: The probability of over diagnosis is strongly influenced by comorbidity status in addition to age. Personalized estimates incorporating comorbidity may contribute to shared decision making between patients and providers regarding personalized treatment selection.

Recent Prescription Patterns for Children With Acute Infectious Diarrhea.

BACKGROUND: This study investigated recent trends in antibiotic use and factors associated with antibiotic use among children with acute infectious diarrhea. We obtained records of outpatients aged under 18 years diagnosed with acute infectious diarrhea from the Japan Medical Data Center database during 2012-2015. OBJECTIVE: We investigated prescription patterns of antibiotics at their initial visit and evaluated factors associated with antibiotic usage using multivariable log-binomial regression models. RESULTS: Overall, we identified 4493 patients diagnosed with acute infectious diarrhea; 29.6% received antibiotics. The most commonly prescribed antibiotic is fosfomycin (20.3%). In multivariable log-binomial regression analysis, out-of-hour visits, clinical diagnoses of suspected bacterial enterocolitis, private outpatient clinics, and pediatric departments are significantly associated with higher prevalence of antibiotic use. CONCLUSIONS: Antibiotics are over-prescribed for children with acute infectious diarrhea. Our investigation provides important information to promote education of physicians and of health policy considerations for appropriate antibiotic prescription practices.

Spatial and temporal trends of cesarean deliveries in Uganda: 2012-2016.

BACKGROUND: Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. METHODS: We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012-2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. RESULTS: Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda's facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35-1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11-2.12) from the baseline in 2016. CONCLUSION: Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.

Audit-based measures of overuse of medical care in Australian hospital practice.

Overuse of care that does not confer benefit to patients and wastes limited resources is being increasingly recognised as a major healthcare problem. The preferred measure of overuse of a specific intervention is applying an evidence- or consensus-based measure of inappropriateness directly to the medical records of individual patients who have received the intervention. This study aimed to assess the extent of overuse of care in hospital practice in Australia based on peer-reviewed literature that reported clinical audits using explicit measures of overuse applied to patient-level clinical data. Thirty-five studies met selection criteria, 14 relating to investigations, 21 to management strategies. Overuse rates above 30% were reported for coagulation tests, blood cultures, troponin assays, abdominal imaging studies, use of telemetry, blood product infusions, polypharmacy in older patients, prescriptions for various medications (gastric acid suppressants, direct oral anticoagulants, inhaled corticosteroids), admissions for low-risk chest pain and futile interventions in end of life care. Hospital physicians may need to audit their current high-volume practices and ensure they align with current criteria of appropriateness.

The clinical utility and adverse consequences of the complete blood count in an internal medicine department.

The clinical utility and adverse consequences of the admission and follow-up complete blood count (CBC) in hospitalised patients are unclear. We selected 273 patients chosen from a single internal medicine department. To determine clinical utility and adverse consequences, we interviewed attending physicians and reviewed patients' charts. There were 12 (4.4%) patients hospitalised because of the CBC test result, six referred appropriately with a low haemoglobin concentration found in outpatient clinics and six (2.2%) patients (95% confidence interval 0.8-4.7%) inappropriately hospitalised because of incidental findings. In the hospital, according to the physicians, nearly all treatment changes made were for blood transfusions that were not indicated in 18 (6.6%) patients (95% confidence interval 4.0-10.2%). The only unexpected findings were in four patients with an indication for a blood transfusion admitted with an acute coronary syndrome and haemoglobin values 8-9.9 g/dL, and in one bedridden patient with dementia with acute myeloid leukaemia. There were 290 follow-up CBC tests not resulting in differential treatment. We conclude that admission CBC tests commonly lead to adverse consequences, due to physician errors in judgement. Incidental findings of anaemia justify CBC testing in patients with an acute coronary event. The rare patient with an incidental finding resulting in appropriate differential treatment might justify non-selective admission CBC counts, if physician education reduces the rate of inappropriate blood transfusions.

A retrospective cross-sectional study of type 2 diabetes overtreatment in patients admitted to the geriatric ward.

BACKGROUND: Glycemic control targets in older patients should be individualized according to functional status and comorbidities. The aim of the study was to identify high-risk patients who had evidence of tight glycemic control and thus at risk of serious hypoglycemia. METHODS: Retrospective cross-sectional study of type 2 diabetes patients admitted to the geriatric ward receiving diabetes medications. Patients' hospital records were analyzed. The high risk of hypoglycemia group constituted patients who were aged 80+ years, diagnosed with dementia, with end- stage renal disease, or with a history of macrovascular complications. The primary outcome measure was hemoglobin A1C (HbA1C) ≤ 7.0% [53 mmol/mol]. RESULTS: Two hundred thirteen patients were included (77.5% women; 49.3% 80+ year-old). 65.3% received sulfonylurea, 39,4%- metformin, 32.9%- insulin, and 4.2%- acarbose (in 61.5% as monotherapy, and in 38.5% combination therapy). We identified 130 patients (60%) as the denominator for the primary outcome measure; 73.1% had a HbA1C value ≤7.0% [53.3 mmol/mol], but 55.4% ≤6,5% [48.8 mmol/mol], and 40.8% ≤6.0% [42 mmol/mol]. CONCLUSIONS: The results show a very high rate of tight glycemic control in older patients admitted to the geriatric ward, for whom higher HbA1C targets are recommended. This indicates the high probability of diabetes overtreatment in this group, associated with a high risk of recurrent hypoglycemia. This is all the more likely because most of them received medications known to cause hypoglycemia. This points to the need of paying more attention to specific difficulties in diabetes treatment in older people, especially those suffering from various geriatric syndromes and diseases worsening their prognosis.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study.

BACKGROUND: At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. METHODS: The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. DISCUSSION: This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

Trends in incidence and 5-year mortality in men with newly diagnosed, metastatic prostate cancer-A population-based analysis of 2 national cohorts.

BACKGROUND: Early detection has increased prostate cancer (PCa) incidence. Randomized trials have demonstrated that early detection reduces the incidence of de novo metastatic PCa. Concurrently, life-prolonging treatments have been introduced for patients with advanced PCa. On a populations-based level, the authors analyzed whether early detection and improved treatments changed the incidence and 5-year mortality of men with de novo metastatic PCa. METHODS: Men diagnosed with PCa during the periods 1980 to 2011 and 1995 to 2011 were identified in the US Surveillance, Epidemiology, and End Results (SEER) program and the Danish Prostate Cancer Registry (DaPCaR), respectively, and stratified according to period of diagnosis. Age-standardized incidence rates were calculated. Five-year mortality rates for de novo metastatic PCa were analyzed using competing risk analysis. RESULTS: Totals of 426,266 and 47,024 men were identified in SEER and DaPCaR, respectively. Of these, 29,555 and 6874 had de novo metastatic PCa. The incidence of de novo metastatic PCa decreased (from 12.0 to 4.4 per 100,000 men) in the SEER cohort (1980-2011), whereas it increased (from 6.7 to 9.9 per 100,000 men) in the DaPCaR cohort (1995-2011). Five-year PCa mortality in the SEER cohort was stable for men diagnosed with de novo metastatic PCa from 1980 to 1994 and increased slightly in the latest periods studied (P < .0001), whereas it decreased by 16.6% (P < .0001) in the DaPCaR cohort. CONCLUSIONS: Despite earlier detection, de novo metastatic PCa remains associated with a high risk of 5-year disease-specific mortality. The reduced 5-year PCa mortality in the Danish cohort is largely explained by lead-time. Early detection strategies do indeed decrease the incidence of de novo metastatic PCa, as observed in the SEER cohort. This achievement, however, must be weighed against the unsolved issue of overdetection and overtreatment of indolent PCa. Cancer 2018;124:2931-8. © 2018 American Cancer Society.

Overdiagnosis and overtreatment in rheumatology: a little caution is in order.

Overdiagnosis is a term coined by experts in cancer screening to point to indolent cancers detected by screening that would have never led to manifest health problems. Overdiagnosis leads to unnecessary medical care (overtreatment), anxiety and cost. In rheumatology overdiagnosis and overtreatment are hardly discussed but likely present. This viewpoint examines how our prevailing views on the management of inflammatory rheumatic diseases may relate to overdiagnosis and overtreatment. Six paradigms of modern rheumatology will be discussed: early diagnosis, intensive treatment, remission, prognosis and risk stratification, evidence-based rheumatology, and precision medicine. It is concluded that, in spite of the enormous progress that they have brought, all paradigms bear the intrinsic dangers of overdiagnosis and overtreatment. So a little caution is in order.

Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence.

PURPOSE: To prevent over diagnosis and overtreatment of vesicoureteral reflux the 2007 NICE (National Institute for Health and Care Excellence) and 2011 AAP (American Academy of Pediatrics) guidelines recommended against routine voiding cystourethrograms in children presenting with first febrile urinary tract infections. The impact of these guidelines on clinical practice is unknown. MATERIALS AND METHODS: Using an administrative claims database (Clinformatics™ Data Mart) children who underwent voiding cystourethrogram studies or had a diagnosis of vesicoureteral reflux between 2001 and 2015 were identified. The cohort was divided into children age 0 to 2 and 3 to 10 years. Single and multiple group interrupted time series analyses (difference-in-difference) were performed with the guidelines as intervention points. The incidence of vesicoureteral reflux was compared across each period. RESULTS: Of the 51,649 children who underwent voiding cystourethrograms 19,422 (38%) were diagnosed with vesicoureteral reflux. In children 0 to 2 years old voiding cystourethrogram use did not decrease after the 2007 NICE guidelines were announced (-0.37, 95% CI -1.50 to 0.77, p = 0.52) but did decrease significantly after the 2011 AAP guidelines were announced (-2.00, 95% CI -3.35 to -0.65, p = 0.004). Among children 3 to 10 years old voiding cystourethrogram use decreased during the entire study period. There was a decrease in the incidence of vesicoureteral reflux in both groups that mirrored patterns of voiding cystourethrogram use. CONCLUSIONS: The 2011 AAP guidelines led to a concurrent decrease in voiding cystourethrogram use and incidence of vesicoureteral reflux among children 0 to 2 years old. Further studies are needed to assess the risks and benefits of reducing the diagnosis of vesicoureteral reflux in young children.