Overscreening

Overscreening, also called unnecessary screening, is the performance of medical screening without a medical indication to do so. Screening is a medical test in a healthy person who is showing no symptoms of a disease and is intended to detect a disease so that a person may prepare to respond to it. Screening is indicated in people who have some threshold risk for getting a disease, but is not indicated in people who are unlikely to develop a disease. Overscreening is a type of unnecessary health care.

Overscreening is problematic because it can lead to risky or harmful additional treatment when a healthy person gets a false positive result for screening which they should not have had. It also causes unnecessary stress for the person receiving the test, and it brings unnecessary financial costs that someone pays.

The general rule is that people should only be screened for a medical condition when there is a reason to believe that they ought to be screened, such a medical guideline recommendation for screening based on evidence from a person's medical history or physical examination.

Controversy and debate arise when new medical guidelines change screening recommendations.

Definition

Screening is a type of medical test which is done on health people who do not show symptoms of a medical condition.[1] Screenings are correctly performed when done on a person who has significant risk of developing a medical condition, and incorrectly performed when done on a person whose risk is not significant.[1]

There can be debate about when risk becomes great enough to become significant and merit a recommendation for screening, but in discussions about overscreening, this is not the cause of the problem. Overscreening almost always happens when a person is screened routinely and without any consideration of their risk for a medical condition.

One early use of the term "overscreening" as "unnecessary screening" was in 1992 in the context of cervical cancer screening.[2]

A 1979 paper used the term "overscreening" to mean "false positive result in a screening".[3]

Causes of overscreening

Same causes as unnecessary health care

Overscreening is a type of unnecessary health care, so the causes of unnecessary health care are also causes of overscreening. Some causes include financial biases for physicians to recommend more treatment in health care systems using fee-for-service and physician self-referral practices; and physicians' practice of defensive medicine.[4][5]

Screening creep

Over time, recommendations to screen are made for populations with less risk in the past.

Clinical practice guidelines advise physicians to screen early to detect diseases.[6] It has been considered that guideline committees might not appropriately do cost-effectiveness analysis, consider opportunity cost, or evaluate risks to patients when they broaden screening recommendations.[6]

Diagnostic creep

Over time, the indicators for making a diagnosis are lower so that people with fewer symptoms are diagnosed with a disease sooner. Additionally, new diseases are named and treatment is recommended, including "subclinical diseases", "preclinical diseases", or "pseudodiseases", which are described as early versions of a disease which has not manifested.[6][7]

Patient demand

Patient demand is a sort of self-diagnosis in which patients request treatment regardless of whether the treatment they request is medically indicated.[6] Causes for patients requesting treatment include increased access to health information on the Internet and direct-to-consumer advertising.[6][8]

Ethical concerns of screening under these circumstances have been described.[9]

Distraction tricks by physicians

Physicians sometimes use screening as a placebo for patients who wish to have some kind of care.[6] The physician may recommend screening to placate the patient's demand for fast recovery in times when the recommended action would be to do nothing except wait.[6] Research suggests that patients are more satisfied with their treatment when it is or seems expensive because patients believe that the more care they get, even if it is not necessary, then at least doing something is better than doing nothing.[6][10]

Arguments against overscreening

Overscreening is a type of unnecessary health care. One study about unnecessary screening before surgery reported that physicians order unnecessary tests because of tradition in the practice of medicine, anticipation that other physicians will expect the test results when they see the patient, defensive medicine, worries that a surgery may be canceled if the test is not done, and lack of understanding about when a test is actually indicated.[11]

False positive medical test results

A false positive medical test result is a false-positive test result of medical screening.[1] It happens when a test indicates that a person has a medical condition when actually the person does not.[1]

Overscreening can be a problem because it can generate a false positive medical test result in a healthy person who does not have the medical condition which screening is supposed to detect.[12] In such cases, the person who received the false positive test is more likely to get further unnecessary screening or even receive treatment for a condition which that person does not have.[12] In either of these cases, the person becomes exposed to the risks and harms of treatment which they ought not be getting.[12]

In general, people should not have medical screening unless the screening is indicated by the person's medical history, a physical examination, and a medical guideline.[12] The rationale for this is that in cases in which a person is unlikely to have a medical condition, it can be more likely that a test will give a false positive result than it would be for the test to detect something which is unlikely considering the person's medical history.[12] If a false positive result does occur in a patient unlikely to have that disease, then that patient will be likely to seek treatment.[12]

Unnecessary costs

Overscreening tends to happen more in circumstances in which medical billing happens based on fee-for-service models rather than bundled payment.[13] One reason for this is because health care providers have incentive to provide more services to increase their revenue.[13] Furthermore, when patients are shielded from cost sharing, that also tends to increase rates of overscreening as when patients pay nothing for additional treatment, they tend to request more services even when they are not indicated.[13]

Overscreening examples

Cancer screening

Prostate cancer screening

The United States Preventive Services Task Force (USPSTF) recommended against PSA screening in healthy men finding that the potential risks outweigh the potential benefits.[14] Guidelines from the American Urological Association,[15] and the American Cancer Society[16] recommend that men be informed of the risks and benefits of screening. The American Society of Clinical Oncology recommends screening be discouraged in those who are expected to live less than ten years, while in those with a life expectancy of greater than ten years a decision should be made by the person in question based on the potential risks and benefits. In general, they conclude that based on recent research, "it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment."[17]

Breast cancer screening

Recommendations to attend to mammography screening vary across countries and organizations, with the most common difference being the age at which screening should begin, and how frequently or if it should be performed, among women at typical risk for developing breast cancer. Some other organizations recommend mammograms begin as early as age 40 in normal-risk women, and take place more frequently, up to once each year. Women at higher risk may benefit from earlier or more frequent screening. Women with one or more first-degree relatives (mother, sister, daughter) with premenopausal breast cancer often begin screening at an earlier age, perhaps at an age 10 years younger than the age when the relative was diagnosed with breast cancer.

Electrocardiography

Electrocardiograms are sometimes inappropriately used to screen low-risk patients with no symptoms for cardiac disease, perhaps as part of a routine annual exam.[18] There is not much evidence that this test in low-risk individuals can improve health outcomes.[18] False positive results, however, are likely to lead to follow-up invasive procedures, unnecessary further treatment, and a misdiagnosis.[18] The harms of a non-indicated annual screening have been determined to outweigh the potential benefit, and for that reason, screening without an indication is discouraged.[18]

Young athletes are sometimes screened with ECG as a requirement for them to play sports, and the necessity of this and harms from false positive results are debated.[19][20]

Heart imaging stress tests

Cardiac stress tests, including stress echocardiography and nuclear stress tests, are used to detect a block in blood flow to the heart. They do this by taking pictures of the heart while the heart is exercising. Persons who have symptoms of heart disease or who are high risk for a heart attack may need this test, while people without these symptoms and who are low risk generally do not.[21]

Coronary computed tomography

Coronary artery calcium scoring is a diagnostic test in the field of cardiovascular x-ray computed tomography. It is used to screen for coronary artery disease. Asymptomatic people who have low risk, including a lack of family history of premature coronary artery disease, should not be screened with this test.[22] Coronary computed tomography angiography should not be used to screen people who are asymptomatic. Additionally, this test rarely provides insight which cannot be gained from coronary artery calcium scoring.[23]

Opinions about overscreening

Overscreening has been called "unethical".[24]

References

  1. 1 2 3 4
    • Wald, N J (2008). "Guidance on terminology". Journal of Medical Screening. 15 (1): 50. doi:10.1258/jms.2008.008got. ISSN 0969-1413. PMID 18416959.
    • Morabia, A; Zhang, F. F. (2004). "History of medical screening: from concepts to action". Postgraduate Medical Journal. 80 (946): 463–469. doi:10.1136/pgmj.2003.018226. ISSN 0032-5473. PMC 1743082. PMID 15299156.
  2. ↑ Please share any example of an earlier use of this term or any claim to coining this term on this article's talk page.
    • McMaster, H; Arroll, B (Apr 8, 1992). "Screening for cervical cancer: attitudes and policies among Auckland general practitioners". The New Zealand Medical Journal. 105 (931): 125–7. PMID 1560922.
  3. ↑ Knobloch, H; Stevens, F; Malone, A; Ellison, P; Risemberg, H (Jun 1979). "The validity of parental reporting of infant development". Pediatrics. 63 (6): 872–8. PMID 88036.
  4. ↑ Horgan, John (November 7, 2011). "How Can We Curb the Medical-Testing Epidemic?". blogs.scientificamerican.com. Retrieved 16 June 2014.
  5. ↑ Kim, Leland (16 August 2012). "Has 'Defensive Medicine' Led to Overtesting?". ucsf.edu. Retrieved 16 June 2014.
  6. 1 2 3 4 5 6 7 8 McGregor, MJ; Martin, D (Nov 2012). "Testing 1, 2, 3: is overtesting undermining patient and system health?". Canadian Family Physician. 58 (11): 1191–3, e615–7. PMC 3498009. PMID 23152453.
  7. ↑ Herman, CR; Gill, HK; Eng, J; Fajardo, LL (Oct 2002). "Screening for preclinical disease: test and disease characteristics". AJR. American Journal of Roentgenology. 179 (4): 825–31. doi:10.2214/ajr.179.4.1790825. PMID 12239019.
  8. ↑ Wilkes, MS; Bell, RA; Kravitz, RL (Mar–Apr 2000). "Direct-to-consumer prescription drug advertising: trends, impact, and implications". Health Affairs (Project Hope). 19 (2): 110–28. doi:10.1377/hlthaff.19.2.110. PMID 10718026.
  9. ↑ Fenton, JJ; Deyo, RA (Nov–Dec 2003). "Patient self-referral for radiologic screening tests: clinical and ethical concerns". The Journal of the American Board of Family Practice. 16 (6): 494–501. doi:10.3122/jabfm.16.6.494. PMID 14963076.
  10. ↑ Fenton, JJ; Jerant, AF; Bertakis, KD; Franks, P (Mar 12, 2012). "The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality". Archives of Internal Medicine. 172 (5): 405–11. doi:10.1001/archinternmed.2011.1662. PMID 22331982.
  11. ↑ Brown, SR; Brown, J (May 2011). "Why do physicians order unnecessary preoperative tests? A qualitative study". Family Medicine. 43 (5): 338–43. PMID 21557104.
  12. 1 2 3 4 5 6 Better citations are needed. The following sources describe the consequences of false positive results for certain conditions. No source is identified which says, "In general for many conditions false positive results are problematic." In these sources, it is said that for the conditions described, false positive results lead to undesirable consequences. The sources seem to presume that all health care providers know the concept of a "false positive" and that it is not a desirable outcome without explaining why generally. Perhaps some textbook describes this concept?
  13. 1 2 3 This sort talks about overscreening without using the term and without being an authoritative review article.
  14. ↑ Harris, Gardner (6 October 2011). "U.S. Panel Says No to Prostate Screening for Healthy Men". New York Times. Retrieved 2011-10-08.
  15. ↑ Greene, KL; Albertsen, PC; Babaian, RJ; Carter, HB; Gann, PH; Han, M; Kuban, DA; Sartor, AO; Stanford, JL; Zietman, A; Carroll, P; American Urological, Association (January 2013). "Prostate specific antigen best practice statement: 2009 update". The Journal of Urology. 189 (1 Suppl): S2–S11. doi:10.1016/j.juro.2012.11.014. PMID 23234625.
  16. ↑ Wolf, AM; Wender, RC; Etzioni, RB; Thompson, IM; D'Amico, AV; Volk, RJ; Brooks, DD; Dash, C; Guessous, I; Andrews, K; DeSantis, C; Smith, RA; American Cancer Society Prostate Cancer Advisory, Committee (Mar–Apr 2010). "American Cancer Society guideline for the early detection of prostate cancer: update 2010". CA: A Cancer Journal for Clinicians. 60 (2): 70–98. doi:10.3322/caac.20066. PMID 20200110.
  17. ↑ Basch, E; Oliver, TK; Vickers, A; Thompson, I; Kantoff, P; Parnes, H; Loblaw, DA; Roth, B; Williams, J; Nam, RK (Jul 16, 2012). "Screening for Prostate Cancer With Prostate-Specific Antigen Testing: American Society of Clinical Oncology Provisional Clinical Opinion". Journal of Clinical Oncology. 30 (24): 3020–5. doi:10.1200/JCO.2012.43.3441. PMC 3776923. PMID 22802323.
  18. 1 2 3 4 American Academy of Family Physicians. "Fifteen Things Physicians and Patients Should Question". Choosing Wisely: An Initiative of the ABIM Foundation. Retrieved September 23, 2013., which cites
  19. ↑ Hobson, Katherine (August 23, 2011). "When Misread Heart Tests Eject Students From Games - WSJ". The Wall Street Journal. New York: Dow Jones. ISSN 0099-9660. Retrieved 13 June 2014.
  20. ↑ Helliker, Kevin; Kranhold, Kathryn (June 21, 2005). "Case Grows for Screening Young Athletes For Dangerous Heart Conditions - WSJ". The Wall Street Journal. New York: Dow Jones. ISSN 0099-9660. Retrieved 13 June 2014.
  21. ↑ American Society of Nuclear Cardiology (February 2013). "Five Things Physicians and Patients Should Question". Choosing Wisely: An Initiative of the ABIM Foundation. Retrieved 1 July 2014., which cites
  22. ↑ Society of Cardiovascular Computed Tomography. "Five Things Physicians and Patients Should Question". Choosing Wisely: An Initiative of the ABIM Foundation. Retrieved October 17, 2013., which cites
  23. ↑ Society of Cardiovascular Computed Tomography. "Five Things Physicians and Patients Should Question". Choosing Wisely: An Initiative of the ABIM Foundation. Retrieved October 17, 2013., which cites
  24. ↑ McCartney, M. (20 July 2011). "Doctors should stop supporting unethical screening". BMJ. 343 (jul20 3): d4592. doi:10.1136/bmj.d4592. PMID 21775396.
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