BMJ Evidenced-Based Medicine最新文献

{"title":"50 Overdiagnosis: a multi level problem","authors":"B. Hofmann, W. Rogers, S. Carter, L. Reid","doi":"10.1136/BMJEBM-2018-111070.50","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.50","url":null,"abstract":"Objectives Overdiagnosis is a complex problem that is challenging to conceptualise and define. This challenge contributes to problems with measuring it and developing ways to decrease rates of overdiagnosis. The objective of this study is to identify the different levels at which overdiagnosis can be conceptualised and defined in order to improve information for patients’ decision making, estimates by health services researchers, and decisions of health policy makers. Method Literature search (for definitions, conceptualisations, and estimates of overdiagnosis), qualitative content analysis, and philosophical concept analysis. Results Overdiagnosis can be defined on three levels: personal, professional, and population. On the personal level overdiagnosis occurs when a person is given a diagnosis of a condition that otherwise would not have progressed to manifest disease. From a professional perspective overdiagnosis is linked to the definition of disease and can be identified in terms of dysfunction that is not at significant risk of causing harm. On a population level overdiagnosis is defined in terms of correct diagnoses that carry an unfavourable balance between benefits and harms. To make sense for individuals, overdiagnosis has to be explained (prognostically) in terms of the individual’s chance of being diagnosed (and treated) for what would otherwise have been manifest disease. Arriving at this information requires attention to professionals’ conception of disease, as well as epidemiologists’ estimates of the proportion of individuals who are diagnosed without overall benefits. Conclusions On a personal level overdiagnosis involves being unnecessarily diagnosed with (and treated for) a disease. To better estimate the chance of this occurring for individuals we need agreement regarding professional conceptions of disease and population-based estimates.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114933327","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"108 Medication review in elderly","authors":"A. Drastrup, H. Jakobsen, G. Madsen, Jón Þór Trærup Andersen, C. Vermehren","doi":"10.1136/bmjebm-2018-111070.108","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.108","url":null,"abstract":"Objectives The number of elderly is increasing in our society. This population group suffers from more chronic diseases and is therefore taking more medications. Polypharmacy and inappropriate use of medication increase the risk of adverse drug reactions and is a contributor to unplanned hospitalization. Therefore, it is important to focus on inappropriate use of medication and to promote rational pharmacotherapy and thereby prevent hospitalization among the elderly. The objective of this pilot study was to develop a medication review model with special focus on the medication taken by elderly living in nursing homes and to investigate and measure the degree of implementation of potential medication changes. The main focus of the medication reviews was on four medications; antibiotic, pain patches, antipsychotics and anti-dementia drugs. Method This study was an intervention study in which medication reviews were performed in corporation between a pharmacist and a consulting physician from the Department of Clinical Pharmacology at Copenhagen University Hospital Bispebjerg in the Capital Region of Denmark and the patients´ general practitioner. Only participants living in nursing homes in the Capital Region of Denmark and in treatment with antibiotic, pain patches, antipsychotics or anti-dementia drugs were included. The intervention consisted of two parts. First the pharmacist and the consulting physician performed a medication review with access to information about the patient´s medication, diagnosis, laboratory result and health information. This was followed by a meeting between the pharmacist, the consulting physician and the patient’s general practitioner in order to discuss the potential changes in the patient´s medication. Finally, a four month follow-up to evaluate the degree of implementation of the accepted medication changes was performed. Results 100 patients were included and 49 informed consents were collected. 30 (61.2%) were females and the average age of the participants was 85.3 years (SD ±9.5). Medication reviews were performed and in total 530 prescriptions were reviewed. In average, the participants were treated with 10.8 medications. 109 interventions were suggested and qualified by the patient´s general practitioner. 99% of the proposed changes were approved by the general practitioner and the most frequent type of intervention was discontinuation (43.5%) followed by dose reduction (23.5%) and reassessment of the treatment (22.6%). Among the 109 interventions only 18.3% were concerning the four medications in focus (antibiotic 4.3%, pain patches 1.7%, antipsychotics 11.3% and anti-dementia drugs 0.9%). After four months 34.3% interventions had been implemented and 2.8% had been partly implemented. Conclusions The type of medication review performed here showed a high degree of approved proposals which can be due to the structure of the medication review. The preliminary result showed that the medications in focus were not","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"361 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122800297","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"92 Systematic review of overdiagnosis in cervical cancer screening: how should we define overdiagnosis in cervical cancer screening?","authors":"C. Hamashima, Teruhiko Hearasawa, T. Katayama, Seijyu Sasaaki, S. Hosono, K. Hoshi","doi":"10.1136/bmjebm-2018-111070.92","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.92","url":null,"abstract":"Objectives Cervical cancer screening is a common strategy for cancer control worldwide. Although its real target is invasive cervical cancer, the incidence has not been high in developed countries, and precancerous lesions have now become the actual target of cervical cancer screening. Therefore, cervical intraepithelial neoplasia (CIN) 3 has now been generally identified as the actual target for early detection and treatment, while, in some countries, CIN2 has become the treatment target. The definition of overdiagnosis in cervical cancer screening has been unclear. Although most cases of CIN have a high possibility of disappearing, CIN2 and CIN3 lesions have been routinely resected when detected by cervical cancer screening. To clarify the traditional concept of overdiagnosis in cervical cancer screening, a systematic review was performed. Method Medline, Cochrane Central, Embase, and Igaku-Cyuo Zasshi were searched until January 2018. The articles were original articles limited to English-language or Japanese-language publications. Search terms such as ‘cervical cancer’, ‘cancer screening’, ‘cytology’, ‘Pap smear’, ‘HPV testing’, and ‘overdiagnosis’ were used. A modeling approach was also included. Additional references cited in candidate articles were included as needed. To select appropriate articles regarding the concept and frequency of overdiagnosis, a two-stage review process was used: the title and abstract were initially checked and then potential papers were subsequently reviewed. Finally, studies of overdiagnosis in cervical cancer screening were selected. Results One modeling reported from the Netherlands and two articles from a Finnish study which included in a randomized controlled trial for HPV testing were selected. In the modelling approach, the frequencies of overdiagnosis in the screening period were estimated to be 74.8% for CIN1+, 68.0% for CIN2+, and 55.4% for CIN3+. Over the subjects’ lifetime, the frequencies of overdiagnosis were 70.6% for CIN1+, 63.2% for CIN2+, and 50.0% CIN3+. In the first report in the Finnish study, the gap in the cumulative incidence of detected invasive cancers between the Pap smear group and the HPV testing group suggested overdiagnosis of HPV testing. Based on a 4.5 year follow-up from the first screening of this study, the frequency of overdiagnosis was 20.3 (/100,000) for Pap smear and 39.6 (/100,000) for HPV testing. Conclusions In cervical cancer screening, precancerous lesions have been identified as the target of cancer screening. These lesions have been resected, and the adoption of this approach has expanded despite the high possibility of the disappearance of these lesions. Overdiagnosis of cervical cancer screening has not been investigated until recently and the studies regarding overdiagnosis have been few. However, its frequency was high in recent reports. Until recently, overdiagnosis has been ignored in cervical cancer screening and has led to overtreatment of precancerous lesion","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121634925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"73 A new explanatory approach to overdiagnosis, based on the bubble theory, using osteoporosis as an example","authors":"C. Haase, J. Brodersen","doi":"10.1136/bmjebm-2018-111070.73","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.73","url":null,"abstract":"Objectives Many individual drivers for overdiagnosis have been identified. Out of those, the economical one has been considered the strongest with the global market of pharmaceuticals now valued at 1.000 billion U.S. dollars and is expected to grow to 1.300 billion in 2020. Despite the common awareness of the above, studies so far lack a more coherent approach explaining the structures and dynamics in society that facilitate overdiagnosis rather than examining its single driver alone. The following study offers a more comprehensive explanation to overdiagnosis, by approaching the concept with the economical point of view as the major tool. Osteoporosis, which is widely accepted as an overdiagnostic condition, is used as an example. The suggested approach opens a new possibility to identify regulations that are needed in order to reduce overdiagnosis and its undesired consequences. Method The analysis is based on abductive methodology, in which evidence about osteoporosis is contextualised into the interdisciplinary bubble theory. This economic theory explains how economical assets are being traded at prices significantly departing from their fundamental value, which constitutes a potential risk of creating a bubble. Latest well-known bubble was the financial crunch in 2008. Recently, the theory has been extrapolated to explain situations in also other fields than finance, such as scientific bubbles, political bubbles and information bubbles. The inflated value of a specific entity, due to various facilitating elements, is what these non-financial scenarios have in common with the financial bubbles. The presented study applies the facilitating elements known from bubble theory to the empirical evidence from osteoporosis. Furthermore, it evaluates the consequences of overdiagnosis in the selected case and its relevance to the other bubbles. Results Doctors, patients, pharmaceutical industry, patient associations etc. all have a stake in the use of the osteoporosis diagnosis. Therefore, they may be considered as distinct actors. The concept of speculation – profiting from trade of the asset instead of its use – correlates with the three main reasons for overdiagnosis (disease mongering, lowering thresholds and over-detection) that are all evident in the case of osteoporosis. Similarly to the financial market, the medical market for osteoporosis seems to be configured in ways to boost the use of the diagnosis. Actors in financial markets are susceptible to social influence and so it seems, in general, in the medical field. By the very definition of a bubble, it can be argued that the development of osteoporosis diagnosis can be seen as one. Conclusions Although there are many similarities, the analogy between bubbles in finance and the situation of osteoporosis as an overdiagnostic condition is not perfect. That is mainly because of insufficient solid and consistent theory of bubbles. However, the bubble theory does offer a new approach to explain ov","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"10 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115878926","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"127 Physical harm resulting from colorectal cancer screening – a systematic review","authors":"F. Martiny, Anne Katrine Lykke Bie, C. Jauernik, O. Rahbek, S. Nielsen, J. Brodersen","doi":"10.1136/BMJEBM-2018-111070.127","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.127","url":null,"abstract":"Objectives Screening for cancer intends to provide benefit but also entails an unintended risk of causing harm. Many types of harm might occur during the screening cascade, including the risk of overdiagnosis due to both overdetection and overdefinition. Regardless of the diagnostic outcome, all screening participants are at risk of enduring physical harms due to screening. Harms of screening are often underreported and asymmetrically presented compared to the benefits of screening. In addition, the definition, measurement and reporting of harms is heterogeneous and of poor quality in clinical studies. These methodological issues have major consequences when systematic reviews do not focus sufficiently on harm assessment methods in studies. As former reviews of colorectal cancer screening have not addressed the above detailed issues, this systematic reviews aims to assess the evidence regarding physical harms of colorectal cancer screening in line with recent methodological recommendations in the PRISMA harms extension. Method Conduct and reporting follows recommendations from the PRISMA harms extension and the Cochrane Handbook. The study protocol was published on PROSPERO prior to data extraction to ensure transparency. Databases were searched in April 2017 and included Pubmed, Medline, Embase, Cinahl, PsycInfo and the Cochrane library. There were no restrictions concerning study design, language or date of publication. All types of clinical studies were included if they provided data on physical harms due to screening of asymptomatic individuals in average risk of colorectal cancer by any combination of fecal occult blood testing, sigmoidoscopy and/or colonoscopy. Using an extended version of the newly published risk of bias tool for non-randomized studies, ROBINS-I by the Cochrane Collaboration, we appraised the risk of bias of the included studies. The overall quality of the evidence will be evaluated using the GRADE criteria. The study protocol is available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=58844 Results Preliminary results and methodological issues identified in studies included for review will be presented at the conference.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"28 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130007478","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"66 Preventing overtreatment in older age by prioritising medicines","authors":"K. Weir, C. Bonner, V. Naganathan, K. McCaffery, A. McLachlan, S. Carter, L. Trevena, Jim Colvin, D. Rigby, J. Jansen","doi":"10.1136/BMJEBM-2018-111070.66","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.66","url":null,"abstract":"Objectives Reducing inappropriate and harmful medicines in older people with comorbidity is a major public health issue. GPs and pharmacists play a pivotal role in optimising medicines and reducing treatment burden. This includes reviewing medicines to confirm they are (still) needed/safe and align with patient goals. Medication reviews conducted by pharmacists aim to resolve problems associated with polypharmacy and involve recommendations to the patient’s GP on how to do this. However, there are barriers to uptake and limited evidence underpinning medication reviews. Our study aimed to explore GP and pharmacists’ views on the role of patient goals and preferences in medication reviews and deprescribing. Method Semi-structured interviews were conducted with GPs (n=25), pharmacists (n=11) who refer to and conduct medication reviews; with varying background characteristics and experience levels. Transcribed audio-recordings of the interviews were coded using Framework Analysis. Results Most participants recognised the importance of getting a sense of patient’s goals/preferences in relation to medicines. However, often these discussions were initiated by the patient, some participants tended to interpret goals only in terms of clinical outcomes (i.e. therapeutic index) and goals were not routinely discussed. Overall, participants considered medication reviews useful for preventing medication errors, reducing treatment burden and to support deprescribing. However, some GPs expressed doubts about the effectiveness of reviews, suggesting they may be limited in what they can achieve as only one aspect of patient care. Important barriers were highlighted related to patients (resistance to the review, misunderstanding about the aim); pharmacists (importance of patient goals/preferences being reflected in recommendations, reviews targeted to high-need patients with recommendations actioned by GPs for patients to benefit) and GPs (limited information from the GP at referral, limited follow-up afterwards and recommendations not being actioned). Conclusions Participants reported a range of benefits for medication reviews in terms of optimising care and reducing medication burden for older people. However, we identified limitations importantly goals and preferences may not be routinely incorporated in decision-making about medicines and some GPs are doubtful as to the clinical benefit of medication reviews. This may influence barriers reported by participants such as patient resistance to reviews, misunderstanding of the purpose and limited follow up afterwards. This study highlights the challenges GPs and pharmacists face in collaboratively managing polypharmacy and providing care that aligns with patient goals and preferences.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"687 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131157147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"75 Evaluation of strategies to prevent overdiagnosis of melanocytic skin lesion biopsies: a decision analysis","authors":"A. Tosteson, Stephanie J. Tapp, L. Titus, H. Nelson, G. Longton, T. Onega, L. Reisch, P. Carney, R. Barnhill, D. Elder, M. Weinstock, M. Piepkorn, J. Elmore","doi":"10.1136/bmjebm-2018-111070.75","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.75","url":null,"abstract":"Objectives The Melanocytic Pathology Study (MPath) reported variation in community pathologists’ interpretations of melanocytic skin lesions relative to reference diagnoses developed through consensus by a panel of three experts. Little is known about the impact of second (2nd) opinion strategies on false positives (FP- overdiagnosis relative to consensus diagnosis) or false negatives (FN-underdiagnosis relative to consensus diagnosis) in melanocytic lesion diagnosis, or on patient care costs incurred within one year of biopsy. Method Lesion severity was classified into five classes based on the nature of clinical follow-up care required. Relative to the reference diagnoses, community pathologists overcalled (FP) or undercalled (FN) as follows: Class I (FP: 7.8%), Class II (FN: 62.8%, FP: 12.5%), Class III (FN: 54.1%, FP: 5.5%), Class IV (FN: 48.1%, FP: 9.1%), Class V (FN: 27.9%). We assessed second opinion strategies on (1) concordance between community pathologists’ diagnoses and diagnoses rendered by the reference panel, and (2) patient care costs incurred during the first year following biopsy. Second opinion strategies assessed included: no 2nd opinion; 2nd opinion obtained for all lesions; 2nd opinion required for some lesions by institutional policyor based on pathologists’ preference. For each second opinion strategy, decision analysis was used to estimate the expected percent of concordant diagnoses, FN, and FP. Standardized care pathways were used to estimate care costs in the year following biopsy. Results Without a 2nd opinion, 83.2% of biopsies received a concordant diagnosis with 8.0% FP and 8.8% FN. Concordance increased under all 2nd opinion strategies and was highest (87.4%) with universally obtained 2nd opinions, resulting in 3.6% FP and 9.1% FN While the proportion of FN cases was fairly consistent across 2nd opinion strategies (range: 8.8% to 9.2%) the proportion FP cases ranged from 3.6% to 7.6%. Per 1 00 000 biopsies, the costs were estimated as $118.6 million with no 2nd opinions, and 127.6 million with 2nd opinions obtained for all lesions. Second opinion strategies based on institutional policy and/or pathologist preference reduced FP cases without appreciable change in FN cases, and led to lower costs in the year following diagnosis (approximately $117 million/100,000). Conclusions While 2nd opinion strategies did not appreciably alter the proportion of FN cases, they did result in fewer FP cases. If selectively implemented, 2nd opinion strategies have the potential to save resources and improve care in the year following biopsy. Such strategies could be mandated through regulatory channels.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"73 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133658494","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"65 Drivers of general health checks in china and the risk of overdiagnosisdrivers of general health checks in china and the risk of overdiagnosis","authors":"Yu Wang, Mengxuan Zou, H. Miao","doi":"10.1136/bmjebm-2018-111070.65","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.65","url":null,"abstract":"Objectives In the last decade, the industry of general health checks has been growing rapidly in China, increasingly people are keen on physical examination. However, there is very few study focusing on general health checks and overdiagnosis compared with the great amount of such studies conducted in many western countries. Therefore, the aim of this study is to explore and analyse the drivers of the prevalence of general health checks in China and its consequence especially overdiagnosis. Method literature review and in-depth interview with stakeholders were used in this study. Results The drivers of the prevalence of general health checks in China are various and complicated, including policy support and government guidance, health system and medical insurance system need to be improved, occurrence of cardiovascular disease (CVD) in China grows faster than expectation and the improvement of public health literacy and attitude to general health checks. Last but not least is the guide of Media and the cultural differences between East and West countries. The general health checks in China is at high risk to develop to overdiagnosis, yet it is not enough for the government or researchers to pay attention to it. Conclusions The current popularity of general health checks and its potential effect on overdiagnosis are inevitable in the development of social economy and health system in China. All stakeholders need to pay attention to this big issue of the situation of general health checks in China and its serious consequence like overdiagnosis. Meanwhile, the government, practitioners, policy makers and scientific researchers should pay attention and deal with them as soon as possible.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"31 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132707178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"80 Overdiagnosis and error in general practice: the need of a new approach","authors":"S. Lorenzo, Alberto Fernández Ajuria, Carmen Fernández Aguilar, J. Martín","doi":"10.1136/bmjebm-2018-111070.80","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.80","url":null,"abstract":"Objectives Diagnostic error (DE) is defined as a diagnosis unintentionally delayed (sufficient information was available earlier), wrong (another diagnosis was made before the correct one), or missed (no diagnosis was ever made) (Graber, 2012). More recently, it has been proposed to include overdiagnosis in DE definition (Zwaan, 2015). Usually, the standard to analyze diagnostic process is the appropriateness of code assigned to a problem using the International Classification of Diseases (ICD). However at least one third of common symptoms do not have a disease-based explanation (Kroenke, 2014). This approach mean all expressions of illness must be associated to a disease label, against the context of general practice (Heath, 2011). ObjectivesTo assess diagnostic codes allocated to new cases of dyspnea in General PracticeTo study diagnostic error in patient attended by dyspnea in Primary CareTo determine the relationship between the occurrence of diagnostic error and patient harm. Method Cohort study of new episodes of dyspnea in patients receiving care from general practitioners (GPs) and GPs trainees at Primary Care Practices in Granada (Spain). In addition to filling out the electronic medical record of the patients attended, each physician fills out two specially designed questionnaires about the diagnostic process performed in each case of dyspnea: the first questionnaire includes questions on the physician’s initial diagnostic impression, the three most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the final diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. Our methods is based on the Zwaan methodology on Diagnostic errors in dyspnea patients treated in Dutch hospitals (Zwaan, 2009). Results Nine general practitioners and five GP trainees participated in this study. Initially, 373 records were collected for a year. 217 new cases of dyspnea were finally registered. Each of them received a diagnostic code by their general practitioner. The average number of cases recorded by each physician was 21.Mean time at until diagnosis was 32.89 days Final diagnosis included acute asthma exacerbation(37), acute bronchitis (34), asthma (30), COPD (27), other disease of respiratory system (26), anxiety (24) and congestive heart failure (20). In peer review process, Diagnostic testing requested were considered appropriate in 81.56% of the cases, Diagnostic process performed was considered not appropriate in 12.44%, and Diagnosis was wrong in 13.2% (32 of 217). Diagnostic error-related harm was not found. However, 4,15% of the cases in which a diagnostic tests were requested, adverse effects were found. Conclusions Although 1/3 of common symptoms don’t have a disease-based e","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"10 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114530910","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"116 The surveillance interval of follow-up colonoscopy after an initial colonoscopy: a retrospective study","authors":"Jun-Hung Lai, Tsai-Wei Huang","doi":"10.1136/bmjebm-2018-111070.116","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.116","url":null,"abstract":"Background More and more people have undergone colonoscopy for colorectal cancer screening. The surveillance interval is up to the patients with low- or high-risk polyps at the first screening. According to the guideline of US Multi-Society Task Force on Colorectal Cancer, they recommend that the surveillance intervals for patients with the low-risk polyps are 5 to 10 years, and for high-risk are 3 years. Aims We would like to investigate what is the time of follow-up interval in the patients (low- and high-risk) at present. Methods We retrospectively study individuals who had undergone surveillance colonoscopy during 2011 through 2017 in a community hospital. Each time colonoscopic findings were divided to two groups: (1) low-risk polyps (2) high-risk polyps. No polyps or small (<10 mm) hyperplastic polyps detected were inclusive to low-risk polyps. Results A total of 55 patients were collected. 40 patients (72.7%) were in low-risk polyps group and 15 (27.3%) were in high-risk polyps group according to their first colonoscopy result. In low-risk group, the average years of follow-up intervals are 3.68 years (SD 2.09), and 27 of 40 patients (67.5%) are less than 5 years (range 1–4 years). Positive fecal occult blood test (29.6%), bloody stool passage (22.2%) and colonic polyps’ history (25.5%) are the common reasons why these patients practiced next screening colonoscopy in advance. In high-risk group, the average years of follow-up intervals are 2.38 years (SD 1.45), and 10 of 15 patients (67.5%) are less than 3 years (range 1–2 years). Colonic polyps’ history (70%) is the most frequent reasons why the patients practiced next screening colonoscopy in advance. Another issue is for age older than 75 years old, 2 of 5 patients had high-risk polyps at first time colonoscopy, however, they all had low risk polyps at follow-up colonoscopy surveillance. Conclusions This study reveals the discrepancy between practitioner recommendations and current guidelines for colonoscopy surveillance in the time of follow-up colonoscopy. It might be caused by frequent fecal occult blood test (biennial), bowel cleansing preparation, and continuing education for practitioners. The Ministry of Health and Welfare must conduct a broader assessment of screening schedule.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114904563","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}