63 Overdiagnosis in the frail elderly population – empirical and ethical issues and a conceptual model to guide change

Overdiagnosis has been described as ‘unwarranted diagnosis’ (Moynihan et al, 2018). It is the formulation and conveyance of a label –generally of a disease or condition - that can lead to patient harm from unnecessary overtreatment, psychological distress or even stigmatisation. Overdiagnosis and overtreatment, are challenging and pervasive problems in modern healthcare systems. They are of particular concern when considered in the context of frail elderly patients. This is because for vulnerable patients with limited physiologic reserves, thresholds for appropriate care can differ from those for the non-frail population – making it more likely that standard approaches to management and care delivery have minimal prospect of meaningful benefit being realised by patients. Diseases that have been identified as overdiagnosed in the frail elderly include chronic kidney disease, and hypothyroidism. Preliminary analyses of data from NSW show that among the 22,211 people aged 85+ years who died during 2016–17, there were 1,560 (7%) with a diagnosis of chronic kidney disease (stage 1–3), and 247 (1%) with a diagnosis of hypothyroidism, noted on a hospital admission in the 12 months prior to their death. Given the extent of over diagnosis in our patient populations, and in particular, among our frail elderly patients – healthcare systems require new ways of thinking about appropriateness - and more meaningful definitions of under- and over-use. There is an imperative to shift practice away from a disease focus to symptom management – changing the way care is delivered to frail elderly patients. Targeting provision around common disability or symptoms rather than the primary organ disease; greater reliance on shared decision making and co-design, and drawing on social support alongside or in some cases, instead of, medical interventions to address patient needs –together represent a step change in models of care delivery. In much of the field, there is significant resonance with the bioethical debates regarding disease screening. A seminal article by Wilson and Junger published over 50 years ago established the principle that looking for a particular diagnosis should only occur when there is a meaningful treatment available that is likely to benefit and that it is incumbent on healthcare providers to determine the appropriate management of borderline cases in order to avoid causing more harm than good. Echoing those principles – diagnosis in frail elderly patients should only be sought when there is a reasonable prospect of better quality of life for patients. This presentation discusses these issues and draws on empirical data and scientific literature to develop a conceptual framework to guide the development of new models of care. It addresses ways to assess the salience of diagnostic processes –taking into account actionability, relative likelihood of effecting a change in patients’ trajectories, and the ability to meet patient needs and expectations. The framework is applied in NSW in the context of quality improvement efforts – particularly those focused on clinical decision making –informing approaches that seek to reset heuristics and established norms in diagnosing disease.