Recognizing the Potential for Overdiagnosis: Are High-Sensitivity Cardiac Troponin Assays an Example?
Authors: Katy J.L. Bell, Jenny Doust, Paul Glasziou, Louise Cullen, Ian A. Harris, Leon Smith, Rachelle Buchbinder, Alexandra Barratt
Journal: Annals of Internal Medicine (2019)

Ideas and Opinions19 February 2019Recognizing the Potential for Overdiagnosis: Are High-Sensitivity Cardiac Troponin Assays an Example?Katy J.L. Bell, MBChB, MMed(Clin Epi), PhD, Jenny Doust, BMBS, PhD, Paul Glasziou, MBBS, PhD, Louise Cullen, MBBS(Hon), PhD, Ian A. Harris, MBBS, MMed(Clin Epi), PhD, Leon Smith, MBBS, Rachelle Buchbinder, MBBS(Hons), MSc, PhD, and Alexandra Barratt, MBBS, MPH, PhDKaty J.L. Bell, MBChB, MMed(Clin Epi), PhDThe University of Sydney, Sydney, New South Wales, Australia (K.J.B., L.S.)Search for more papers by this author, Jenny Doust, BMBS, PhDBond University, Gold Coast, Queensland, Australia (J.D., P.G.)Search for more papers by this author, Paul Glasziou, MBBS, PhDBond University, Gold Coast, Queensland, Australia (J.D., P.G.)Search for more papers by this author, Louise Cullen, MBBS(Hon), PhDUniversity of Queensland, Brisbane, Queensland, Australia (L.C.)Search for more papers by this author, Ian A. Harris, MBBS, MMed(Clin Epi), PhDThe University of Sydney, Ingham Institute of Applied Medical Research, and South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia (I.A.H.)Search for more papers by this author, Leon Smith, MBBSThe University of Sydney, Sydney, New South Wales, Australia (K.J.B., L.S.)Search for more papers by this author, Rachelle Buchbinder, MBBS(Hons), MSc, PhDCabrini Institute and Monash University, Melbourne, Victoria, Australia (R.B.)Search for more papers by this author, and Alexandra Barratt, MBBS, MPH, PhDWiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia (A.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-2645 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Overdiagnosis occurs when persons are labeled with a technically correct diagnosis that does not improve health outcomes (1). It is a common unintended consequence of early disease detection in asymptomatic persons but also takes place in persons with mild or ambiguous symptoms. Despite initiatives to prevent overdiagnosis (2), new tests and changes to disease definitions may become established in clinical practice before their potential for overdiagnosis is recognized; as such, reverting to previous approaches may be difficult. In this commentary, we propose questions (Figure) to identify new practices with the potential for overdiagnosis and evaluate the example of using high-sensitivity ...References1. Carter SM, Degeling C, Doust J, Barratt A. A definition and ethical evaluation of overdiagnosis. J Med Ethics. 2016;42:705-14. [PMID: 27402883] doi:10.1136/medethics-2015-102928 CrossrefMedlineGoogle Scholar2. Doust J, Vandvik PO, Qaseem A, Mustafa RA, Horvath AR, Frances A, et al; Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group. Guidance for modifying the definition of diseases: a checklist. JAMA Intern Med. 2017;177:1020-5. [PMID: 28505266] doi:10.1001/jamainternmed.2017.1302 CrossrefMedlineGoogle Scholar3. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102:605-13. [PMID: 20413742] doi:10.1093/jnci/djq099 CrossrefMedlineGoogle Scholar4. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171:831-7. [PMID: 21555660] doi:10.1001/archinternmed.2011.178 CrossrefMedlineGoogle Scholar5. de Lemos JA, Drazner MH, Omland T, Ayers CR, Khera A, Rohatgi A, et al. Association of troponin T detected with a highly sensitive assay and cardiac structure and mortality risk in the general population. JAMA. 2010;304:2503-12. [PMID: 21139111] doi:10.1001/jama.2010.1768 CrossrefMedlineGoogle Scholar6. Shah ASV, Anand A, Strachan FE, Ferry AV, Lee KK, Chapman AR, et al; High-STEACS Investigators. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet. 2018;392:919-28. [PMID: 30170853] doi:10.1016/S0140-6736(18)31923-8 CrossrefMedlineGoogle Scholar7. de Groot JAH, Naaktgeboren CA, Reitsma JB, Moons KGM. Methodologic approaches to evaluating new highly sensitive diagnostic tests: avoiding overdiagnosis. CMAJ. 2017;189:E64-8. [PMID: 27378465] doi:10.1503/cmaj.150999 CrossrefMedlineGoogle Scholar8. Glasziou P, Irwig L, Deeks JJ. When should a new test become the current reference standard? Ann Intern Med. 2008;149:816-22. [PMID: 19047029] LinkGoogle Scholar9. Lord SJ, Staub LP, Bossuyt PM, Irwig LM. Target practice: choosing target conditions for test accuracy studies that are relevant to clinical practice. BMJ. 2011;343:d4684. [PMID: 21903693] doi:10.1136/bmj.d4684 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: The University of Sydney, Sydney, New South Wales, Australia (K.J.B., L.S.)Bond University, Gold Coast, Queensland, Australia (J.D., P.G.)University of Queensland, Brisbane, Queensland, Australia (L.C.)The University of Sydney, Ingham Institute of Applied Medical Research, and South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia (I.A.H.)Cabrini Institute and Monash University, Melbourne, Victoria, Australia (R.B.)Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia (A.B.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2645.Corresponding Author: Katy J.L. Bell, MBChB, MMed(Clin Epi), PhD, School of Public Health, Edward Ford Building (A27), The University of Sydney, Sydney, NSW 2006, Australia; e-mail, katy.[email protected]edu.au.Current Author Addresses: Drs. Bell and Barratt: School of Public Health, Edward Ford Building (A27), The University of Sydney, Sydney, NSW 2006, Australia.Drs. Doust and Glasziou: Centre for Research in Evidence-Based Practice, Health Sciences and Medicine, Bond University, Bond, QLD 4229, Australia.Dr. Cullen: Royal Brisbane & Women's Hospital, Butterfield Street, Herston, Brisbane, QLD 4029, Australia.Dr. Harris: Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170, Australia.Dr. Smith: Hornsby Hospital, 36–38 Palmertson Road, Hornsby, NSW 2077, Australia.Dr. Buchbinder: 4 Drysdale Street, Malvern, VIC 3144, Australia.Author Contributions: Conception and design: K.J.L. Bell, J. Doust, I.A. Harris, R. Buchbinder, A. Barratt.Analysis and interpretation of the data: K.J.L. Bell, J. Doust, L. Cullen, I.A. Harris.Drafting of the article: K.J.L. Bell, J. Doust, L. Cullen, I.A. Harris, A. Barratt.Critical revision of the article for important intellectual content: K.J.L. Bell, J. Doust, P. Glasziou, L. Cullen, I.A. Harris, L. Smith, R. Buchbinder, A. Barratt.Final approval of the article: K.J.L. Bell, J. Doust, P. Glasziou, L. Cullen, I.A. Harris, R. Buchbinder, A. Barratt.Statistical expertise: K.J.L. Bell.Obtaining of funding: J. Doust, A. Barratt.Administrative, technical, or logistic support: K.J.L. Bell, P. Glasziou.Collection and assembly of data: K.J.L. Bell.This article was published at Annals.org on 5 February 2019. 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