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Reducing harm and waste in healthcare

Allocating resources and reducing harm and waste in health systems

This theme is focused on how resources should be used in healthcare.

This includes work on health technology assessment, including research to answer questions about how judgements are made in the assessment process, and work to incorporate the judgements of consumers and members of the public into decision making processes.

We are also researching a common problem in healthcare systems: overuse of tests, treatment and services. There are different types of overuse in healthcare. These include doing unnecessary tests (over-testing), giving people diagnoses that they don’t need (overdiagnosis), or providing treatments or services that don’t work or make things worse (overtreatment). Unnecessary interventions can harm people and waste valuable healthcare resources that should be spent in areas of need. In this theme, we ask questions about how to understand the problem of healthcare overuse, and what to do about it, especially when people disagree.

With our colleagues at Wiser Healthcare, we are exploring these complex problems to contribute to better communication strategies and solutions. Our work focuses on diverse examples, including transvaginal mesh, direct to consumer pathology testing, and screening for disease. Our goal is to understand the diversity of people’s views on these complex problems, and to help make healthcare less harmful and more equitable.

 

Projects

Researchers

Project description

Overdiagnosis is a difficult concept to define, and it’s even more difficult to determine what should be done about it.

Our team has played a pivotal role in efforts to better define and respond to overdiagnosis. Roughly speaking, overdiagnosis is diagnosis that is both unnecessary and harmful. It happens when health systems have their default settings in the wrong place, so that people who diagnosed with, and treated for, conditions that really weren’t clinically important.

Most treatments cause some harm, but we tolerate this because they also offer benefits. When overdiagnosis happens, health systems routinely diagnose people in ways that cause more harm than good. It’s especially likely to happen when testing technology gets more and more sensitive (so can pick up smaller and smaller changes, that might not mean anything), or when medical experts decide to lower the threshold at which they will diagnose a disease.

Overdiagnosis is now a big problem in healthcare. For example, our Wiser Healthcare colleagues have shown that approximately 11,000 cancers in women and 18,000 in men may be overdiagnosed in Australia each year—and overdiagnosis is a problem in many other conditions too. We have worked with colleagues nationally and internationally on some tough questions about overdiagnosis, particularly: how should we define it, and what are its ethical implications?  This work is ongoing: our relevant papers are linked below.

Outcomes

 

Researchers

Project description

Wiser Healthcare is a research collaboration for reducing overdiagnosis and overtreatment. It involves more than 100 researchers from The University of Sydney, Bond University, Monash University, the University of Wollongong, as well as international colleagues. We investigate the cause and size of the problem and test new solutions, in the areas of cancer, cardiovascular disease and musculoskeletal disorders, with a particular focus on overdiagnosis caused by imaging (like CT scans and MRI scans), testing biomarkers (for example, blood tests like the Prostate Specific Antigen test), and genetic tests. Wiser Healthcare led the development of a National Action Plan on overdiagnosis, and are closely connected to the international Preventing Overdiagnosis Conference. 

ACHEEV contributes qualitative research, community juries, ethics research and fundamental work on the definitions of overdiagnosis to Wiser Healthcare. You can find more information about specific projects below.

Funding

Funding for Wiser Healthcare includes NHMRC Centre for Research Excellence #1104136: 2017-2022 $2,497,658

Outcomes

We have conducted several community jury projects within Wiser Healthcare. Reports from these juries are linked below.

Researchers

Project description

NIPS stands for Non-Invasive Prenatal Screening. NIPS is a relatively new test used in pregnancy, which can find genetic information about a fetus from about 9 weeks into a pregnancy. NIPS is only used to tell people whether they or the fetus are at an increased chance of having a condition. It can’t provide a definite diagnosis, and sometimes gives a false positive (a wrong result). It performs better than other tests for some conditions. However NIPS is also being used for some conditions where it can be unclear what to do with the results, because it is hard to interpret, or there are not diagnostic tests available to follow up on the NIPS result. These NIPS results can cause a lot of uncertainty for a woman or couple. We convened groups of Australians to discuss scenarios in which NIPS might be offered to pregnant women or couples. The discussions focused on whether it was a good thing, on balance, to use NIPS in this way.

Funding

This project was funded under NHMRC Centre for Research Excellence #1104136: 2017-2022 $2,497,658

Outcomes

Data collection has completed – we hope to have outcomes to link here soon.

Researchers

Professor Stacy Carter 

as part of a team led by Dr Tomas Rozbroj (Monash University) with Dr Romi Haas (Monash University)

Project description

Overdiagnosis is a difficult concept to communicate and understand. In this project, led by researchers from Monash University, researchers synthesised data from 21 separate studies, covering 1,638 participants, to explain how people make sense of overdiagnosis. We make recommendations for how the concept of overdiagnosis should be communicated more effectively.

Outcomes

 

Researchers

Project Description

The aim of this project is to elicit views of informed members of the public on whether small low-risk small papillary thyroid cancers that are very unlikely to cause harm should be renamed and reclassified, so that they are no longer called cancers, or diagnosed as cancers.

We convened three community juries in Sydney, Wodonga and Cairns between December 2019 and March 2020, each comprising of 13 to 14 members of the public (total of 40) from diverse backgrounds and ages.

Jury 1 (Sydney) voted 11-2 opposing changes to the terminology. Neither Jury 2 (Wodonga), nor Jury 3 (Cairns) were able to reach a majority position, indicating the highly complex nature of the topic, and that many jurors felt there were important and convincing reasons for both supporting and opposing terminology change.

The results of the community juries showed that a pathologically accurate definition of disease (‘cancer is cancer’) offers clinicians and patients a sense of objectivity in the assessment of the risk of spread and growth of the disease, even when this is minimal. On the other hand, an outcomes-based definition of disease (‘not cancer if it doesn’t behave like cancer’) highlights the power of disease terminology to de-escalate the distress patients experience from their diagnosis. These are two very different ways to approach the issue of thyroid cancer terminology, and the difficulty in choosing one position over the other among jurors highlights this as a key challenge in disease terminology change as a strategy to respond to overdiagnosis and overtreatment. Regardless of action on terminology, the juries had a strong expectation that practical changes would be made to respond to the harms of overdiagnosis and overtreatment.

Project partners

Funding

Wiser Healthcare, a National Health and Medical Research Council Centre for Research Excellence.

Outcomes

Terminology Change for Small Low-Risk Papillary Thyroid Cancer As a Response to Overtreatment: Results from Three Australian Community Juries

 

Researchers

Dr Chris Degeling and Professor Stacy Carter

Project Description

This project examines how the rapid de-implementation of full-body CT scans in Australia arose from interconnected social, cultural and system factors, and an unusual harm profile for the technology. In the Australian context, our research suggests that neither single actors nor robust health technology assessments are likely to be sufficient to protect people from the unwanted consequences of too much medicine.

Funding

Wiser Healthcare

Outcomes

The introduction and demise of full-body computed tomography (CT) scanning in Australia: implications for preventing overdiagnosis