Overdiagnosis can be defined as “when the diagnosis is correct according to current standards of diagnosis but where the patient does not benefit from that diagnosis,” in other words, the patient is better off not knowing.

Pathology’s role in this debate is unique. Despite being the medical discipline performing diagnostic tests (and other tests), pathology labs are not responsible for ordering tests, and unless the circumstances are exceptional, pathology labs do not discuss results with patients directly.

If the pathology profession is simply responding to the needs of doctors (and their patients), is this really pathology’s problem?

A review of the evidence suggests that although there is over-testing in some areas, there is far more under-testing going on. Published in the Public Library of Science, (PLoS) 1 in 2013, The Landscape of Inappropriate Laboratory Testing: A 15-Year MetaAnalysis showed that on average, the rate of pathology overuse was 20.6% but pathology underuse was 44.8%.

In the study, underutilization of pathology refers to tests indicated but not ordered. This means where a doctor would have grounds to order a test – for example based on symptoms or family history – but chooses not to request the test for that patient.

The research suggested that earlier use of pathology testing during medical investigations could lead to better care.

Although we can clearly improve on overuse of pathology, we need to be very careful that we don’t view every negative or normal result as an over-test.

Normal results are powerful for patient peace of mind, and they help doctors in their differential diagnosis process – ruling out the first round of possibilities before other avenues are explored – including more expensive, time-consuming or invasive procedures.

Pathology is pivotal in preventative healthcare – for example, detecting a high glycated haemoglobin (HbA1c) result could trigger someone to make lifestyle changes that improve their health and help them stave off Type II diabetes.

This is where education and communication can be better utilised to create the balance we need.

When ordering tests, General Practitioners assess what is appropriate given a patient’s symptoms, medical history, age and other factors affecting disease risk. However, it’s important that patients understand this process – what the tests are, why they are being recommended and that testing is optional, patients can choose not to be tested or to delay testing if they wish.

In addition to the five questions that NPS MedicineWise recommends a patient ask their doctor before having any test or procedure, we could add one more: what will the results tell me?

In addition to knowing why a doctor is recommending the test, a patient should understand what the results might tell them. For example, will the result be delivered as a diagnostic positive/ negative? Will it show an increased risk to be managed for the future?

There are many different types of pathology test – some will detect a disease, some will show levels of chemicals such as hormones, proteins, antigens in the blood, some results will identify genes linked to disease. All of these results have different meanings and implications for treatment or other next steps. This information could inform a patient’s decision about whether to have the test and make receiving the results easier as they will know what to expect.

To support clinicians in their communication with patients, pathologists and medical scientists spend significant time in conversation with treating doctors, helping them make sense of pathology results and slotting them into the bigger medical puzzle.

As well as being part of the medical puzzle for individuals, pathology is an important public health tool.

The National Notifiable Diseases Surveillance System relies on pathology testing to confirm a number of diseases that have public health implications. This allows health authorities to track outbreaks of communicable diseases, food or water borne illnesses and to monitor epidemics and seasonal variations.

Without laboratory confirmation accurate tracking of these diseases would be impossible, leaving health authorities in the dark and potentially placing people in danger unnecessarily.

Discouraging doctors from doing ‘too much testing’ or giving reluctant patients further reason to avoid the doctor’s office could have consequences beyond the individual. On the flipside, promoting health literacy across the population enables people to make better decisions about their health and can improve patient-doctor interactions.

Some trusted sources of information that can help clinicians educate their patients about pathology include the Know Pathology Know Healthcare initiative, we partner with Lab Tests Online for in depth information about individual tests for consumers.

Patient education should be a shared responsibility across the health professions, as well as for patients themselves, but the power of the informed patient to create a healthier nation should not be underestimated.

The post Fear of overdiagnosis could put preventative healthcare in danger first appeared on Know Pathology Know Healthcare.

But according to an article by The New England Journal of Medicine (NEJM) from 2008, the economic case for preventive healthcare spending is by no means clear cut. In some cases – like flu vaccinations or colonoscopies – there is a health benefit and cost saving, in other cases the cost-benefit is negligible or poor.

In the first phase of preventive medicine, proponents suggested better health and economic outcomes were possible through early detection of conditions, only to have detractors point out the enormous scope of the enterprise, warning about misleading statements about its supposed benefits.

Up like a rocket, down like a stick: the case for spending on preventive healthcare seemed to be knocked into a cocked hat, a medical cul-de-sac. Or perhaps not.

A recent 2017 Australian study by La Trobe University’s Department of Public Health, suggests that preventive medicine does indeed have an important role to play in the Australian health landscape, stating ‘There is clear evidence that many preventive health interventions are cost-effective.’

Like the NEJM article, the La Trobe study’s authors accept that spending on preventive healthcare is not a panacea for all cases and needs to be strategically targeted, but the benefits of doing so could be significant.

Referencing the 2010 Assessing Cost-Effectiveness (ACE) in Prevention study by the University of Queensland and Deakin University – which looks at the benefits of campaigns around tobacco, alcohol, unhealthy foods, gastric banding, and a raft of other measures – the La Trobe study authors state ‘the evidence considered suggests a strong case can be made for increasing spending on preventive health.’

As Michael Thorn of the Foundation for Alcohol Research and Education (FARE) points out, a third of all chronic diseases are preventable and can be traced back to four lifestyle factors: alcohol use, tobacco use, physical inactivity, and poor nutrition. Preventive medicine in those areas, from education to pathology tests, would make sense.

One area of health that certainly would benefit from preventive healthcare spending is on type 2 diabetes. Indeed the case for a national roll-out of the relatively new HbA1c test – which measures glycated haemoglobin in the body – is strong.

In a 2016 trial program run at Mt Druitt Hospital in Blacktown, anyone over 18 presenting to the Emergency Department for blood tests were also given the HbA1c test. The findings were striking.

In the two years from mid-2016 to mid-2018, 48,000 samples were taken, with 47 per cent of those tested presenting with diabetes or prediabetes.

While Blacktown is in the electorate of Chifley, the seat with the highest incidence of diabetes in Australia at 7.8 per cent, the residence of Chifley are not exactly outliers. The national diabetes average is 6 per cent, with 1.2 million Australians living with diagnosed diabetes and a further 500,000 thought to be living with undiagnosed diabetes.

According to the the Centre for International Economics (CIE) 2018 report the prognosis for diabetes in the future is alarming, with 3.5 million Australians projected to be living with diabetes by 2030.

A person can have diabetes for seven years before it symptoms are evident, during which time it’s doing damage to the body. Fortunately, the Centre for International Economics (CIE) 2018 report states that if diabetes is detected and treated early before macrovascular complications ensue, it can more than halve treatment costs.

Given the direct costs of diabetes to the health budget are $1.7 billion a year, with indirect costs to the economy as high as $14 billion, a preventive health program that can significantly cut treatment costs seems like an absolute no brainer.

While it’s not feasible to test every Australian for every condition, that does not preclude smart, targeted testing for specific conditions, such as the bowel screening test for those aged 50-74, diabetes testing for those with a waistline over 102cms, or cervical testing for women with human papillomavirus (HPV), immune deficiency and other risk factors.

Government spending on pathology services in Australia represents just 2.7 per cent of the health budget, while 70 per cent of medical treatment decisions rely on pathology.

With Medicare spending forecast to climb over 25 per cent by 2027-28 from $855 to $1,071 per person that puts even more of a premium on finding ways to reduce health costs by way of preventative medicine, of which pathology testing is central.

So rather than throw the baby out with bathwater, we suggest some targeted funding for targeted testing campaigns that can deliver those health and economic outcomes we all hope for.

The post The case for targeted preventive healthcare first appeared on Know Pathology Know Healthcare.