Too much medicine

Overdiagnosis means different things to different people, say S M Carter and colleagues in their exploration of the social and ethical dimensions of too much medicine (doi:10.1136/bmj.h869). Born out of the Preventing Overdiagnosis 2014 conference in Oxford, their article and others in this special collection (thebmj.com/specialties/digital-theme-issue-overdiagnosis) serve to presage the next conference in Washington, DC, in October 2015, for which registration is now open (www.preventingoverdiagnosis.net). There is much to discuss: how should we define overdiagnosis and its ugly siblings overtreatment, medicalisation, and disease mongering; what do we know of their causes; and what evidence based solutions are available, both general and specific? Above all, who gets to judge when care is inappropriate in any individual case? Pulling this theme issue together, Helen Macdonald and Elizabeth Loder conclude that decisions on what constitutes “just right” medicine are best made by individual patients in true collaboration with their doctors, armed as far as possible with relevant, reliable, and independent information about benefits and harms (doi:10.1136/bmj.h1163).

Therein lies the rub. How good is the available evidence base? When it comes to new drugs entering the market, not very, say Michael Köhler and colleagues (doi:10.1136/bmj.h796); but new legislation in Germany may help and should be adopted internationally, they add. Drug companies wanting to market their drugs in Germany must now provide a standardised dossier containing all available evidence of the drug’s benefits, with special emphasis on outcomes relevant to patients and how the drug compares with existing competitors. Köhler and colleagues found that, in comparison with conventional sources of publicly available information about new drugs (such as journal articles and registry reports), the information in the dossier was far more complete and clinically relevant.

This sounds like progress, even if, as Peter Doshi and Tom Jefferson say in their linked editorial, it’s odd that clinical study reports aren’t included (doi:10.1136/bmj.h952). We know from the Tamiflu saga, on which Doshi and Jefferson worked, that these long and complex documents that drug companies submit to regulators provide invaluable information that should be in the public domain. Excluding them because content is “commercially confidential” seems out of date, they say, especially since the European Medicines Agency has pledged to release all clinical study reports in its possession.

Even so, Germany and its Institute for Quality and Efficiency in Health Care are setting an international standard for other countries to follow. The same might have been said of the UK’s Quality and Outcomes Framework (QOF), the world’s largest pay for performance scheme. As Grant Russell says in his editorial, this grand experiment has been closely watched around the world (doi:10.1136/bmj.h1051), but Evangelos Kontopantelis and colleagues have now provided what Russell believes to be the best evidence on its lack of effect in terms of population health (doi:10.1136/bmj.h904). They found no significant relation between practice performance and either all cause mortality or cause specific mortality. Social deprivation remained the main predictor of mortality.

Whether QOF’s financial incentives to investigate and prescribe have also caused harm and waste from too much medicine is work for another day.