Reforming disease definitions: a new primary care led, people-centred approach

Enablers and barriers to a quaternary prevention approach: a qualitative study of field experts

OBJECTIVE

There is a growing concern about the sustainability of healthcare and the impacts of 'overuse' on patients and systems. Quaternary prevention (P4), a concept promoting the protection of patients from medical interventions in which harms outweigh benefits, is well positioned to stimulate reflection and inspire solutions, yet has not been widely adopted. We sought to identify enablers and barriers to a P4 approach, according to field experts and advocates in one health system.

DESIGN

Qualitative methodology, using semistructured interviews and a grounded theory approach facilitated thematic analysis and development of a conceptual model.

SETTING

Virtual interviews, conducted in British Columbia, Canada.

PARTICIPANTS

12 field experts, recruited based on their interest and work related to P4 and related concepts.

RESULTS

Four factors were seen as promoting or hindering P4 efforts depending on context: relationship between patient and clinician, education of clinicians and the public, health system design and influencers. We extracted four broad enablers of P4: evidence-based medicine, personal experiences and questioning attitude, public P4 campaigns and experience in resource-poor contexts. There were six barriers: peer pressure between clinicians, awareness and screening campaigns, cognitive biases, cultural factors, complexity of the problem and industry influence.

CONCLUSIONS

Elicited facilitators and impediments to the application of P4 were similar to those seen in existing literature but framed uniquely; our findings place increased emphasis on the clinician-patient relationship as central to decision-making and position other drivers as influencing this relationship. A transition to a model of care that explicitly integrates conscious protection of patients by reducing overtesting, overdiagnosis and overtreatment will require changes across health systems and society.

Revisiting the Definition of 'Healthy' Participants in Substantiation of Structure/Function Claims for Dietary Supplements

Concepts and definitions of 'healthy' have been evolving within clinical treatment algorithms as well as reference standards such as Body Mass Index and Dietary Reference Intakes. Consumers' perception of the word 'healthy' is also changing to reflect longer life span, need to stay active and in a good state of mental well-being while managing multiple diseases. Guidelines from the US Food and Drug Administration indicate that substantiating evidence for support of Structure/Function (S/F) claims for dietary supplements is best derived from clinical research conducted in a 'healthy' population. S/F claims cannot be represented to diagnose, treat, cure or prevent any disease. However, in this context, the term 'healthy' is non-descriptive and largely interpreted as an absence of disease. Guidelines for treatment of disease have been broadened to include biomarkers of disease risk such that the pool of 'healthy' volunteers eligible to be enrolled in clinical trials for S/F claim substantiation is greatly diminished. This perspective presents the challenges faced by the food and dietary supplement industry and by researcher efforts designed to substantiate S/F claims and suggest the phrase 'physiologically stable' or 'apparently healthy' as descriptions better suited to replace the term 'healthy.'

Advancing Universal Oral Health Coverage via Person-Centred Outcomes

The World Health Organization member states proposed a comprehensive "Global Strategy on Oral Health," which includes achieving universal oral health coverage by 2030. Challenges and barriers, including persistent inequalities, will hamper the achievement of universal oral health coverage. In low- and middle-income countries, the oral health of a large proportion of the population has been neglected, increasing oral health inequalities. In high-income countries, some receive excessive dental treatment, whilst particularly those with higher needs receive too little dental care. Therefore, an analysis of individual countries' needs, encompassing the training of oral health professionals in a new philosophy of care and attention and the optimisation of the existing resources, is necessary. Distancing from a person-centred focus has prompted individual and societal issues, including under-/overdiagnosis and under-/overtreatment. The person-centred approach considers the perceptions, needs, preferences, and circumstances of individuals and populations. Patient-reported outcome measures, such as self-rated and -reported health, reflect an individual's overall perception of health and are designed to mediate human biology (ie, the disease) and psychology. The usage of patient-reported outcome measures in dentistry to place the individual at the centre of treatment is delayed compared to other areas. This paper discusses some challenges and potential solutions of patient-reported outcome measures in dentistry for achieving universal oral health coverage.

Justification for the 2017 periodontitis classification in the light of the Checklist for Modifying Disease Definitions: A narrative review

Once a while, disease classifications have needed revision because new knowledge has accumulated, and new technologies and better treatments have emerged. Changes made to disease classifications should be trustworthy and openly justified. The periodontitis definition and classification system was changed in 2017 by the 'World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions'. The workshop, comprising clinicians and researchers, resulted in the production of a 23-article special issue that introduced the new definitions and classifications of periodontitis. In this narrative review, we critically review how the changes made to the periodontitis definition and classification were justified in the light of the Checklist for Modifying Disease Definitions. Under each of the eight items of the checklist, we have discussed how the item was or could have been considered in the light of the checklist and its guidance. In our view, the new definition and classification of periodontitis was presented in an understandable way, even though the changes from the previous definition were not made visible. However, the issues of (1) estimated changes in prevalence or incidence, (2) triggers for the change, (3) prognostic ability, (4) repeatability or reproducibility, (5) incremental benefits, (6) incremental harms or (7) net benefits and harms related to the introduction of new classification were not considered in the way suggested in the checklist. Thereby, a balanced assessment of potential benefits and harms associated with the new periodontitis classification system was not presented, and to a large extent it remains unknown if the use of the new classification system will provide more net benefits to patients and to the community than previous systems. It is our view that patients and societies deserve transparent and balanced assessments of the potential benefits and harms associated with the periodontitis classification. Importantly, these should reflect the values and preferences also of the patients and the wider community and consider the impact on resource usage.

Dynamics of tuberculosis infection in various populations during the 19th and 20th century: The impact of conservative and pharmaceutical treatments

Humans and Mycobacterium tuberculosis have co-evolved together for thousands of years. Many individuals are infected with the bacterium, but few show signs and symptoms of tuberculosis (TB). Pharmacotherapy to treat those who develop disease is useful, but drug resistance and non-adherence significantly impact the efficacy of these treatments. Prior to the introduction of antibiotic therapies, public health strategies were used to reduce TB mortality. This work shows how these strategies were able to reduce TB mortality in 19th and 20th century populations, compared with antibiotic treatments. Previously published mortality data from historical records for several populations (Switzerland, Germany, England and Wales, Scotland, USA, Japan, Brazil and South Africa) were used. Curvilinear regression was used to examine the reduction in mortality before and after the introduction of antibiotic treatments (1946). A strong decline in TB mortality was already occurring in Switzerland, Germany, England and Wales, Scotland and the USA prior to the introduction of antibiotic treatment. This occurred following many public health interventions including improved sanitation, compulsory reporting of TB cases, diagnostic techniques and sanatoria treatments. Following the introduction of antibiotics, mortality rates declined further, however, this had a smaller effect than the previously employed strategies. In Japan, Brazil and South Africa, reductions in mortality rates were largely driven by antibiotic treatments that caused rapid decline of mortality, with a smaller contribution from public health strategies. For the development of active disease, immune status is important. Individuals infected with the bacterium are more likely to develop signs and symptoms if their immune function is reduced. Effective strategies against TB can therefore include enhancing immune function of the population by improving nutrition, as well as reducing transmission by improving living conditions and public health. This has been effective in the past. Improving immunity may be an important strategy against drug resistant TB.

On the Ethics of Withholding and Withdrawing Unwarranted Diagnoses

The number of diagnoses and the number of persons having diagnoses have increased substantially, and studies indicate that diagnoses are given or upheld even if they are unwarranted, that is, that they do not satisfy professionally accepted diagnostic criteria. In this article, the authors investigate the ethics of withholding and withdrawing unwarranted diagnoses. First, they investigate ethical aspects that make it difficult to withhold and to withdraw such diagnoses. Second, they scrutinize whether there are psychological factors, both in persons/patients and healthcare professionals, making it difficult to withdraw and withhold unwarranted diagnoses. Lastly, they use recent elements of the withholding-versus-withdrawing treatment debate in medical ethics to investigate whether there are any differences between withholding and withdrawing treatment and withdrawing and withholding unwarranted diagnoses. The authors conclude that it is crucial to acknowledge and address all these issues to reduce and avoid unwarranted diagnoses.

Too Much, Too Mild, Too Early: Diagnosing the Excessive Expansion of Diagnoses

Tremendous scientific and technological advances have vastly improved diagnostics. At the same time, false alarms, overdiagnosis, medicalization, and overdetection have emerged as pervasive challenges undermining the quality of healthcare and sustainable clinical practice. Despite much attention, there is no clarity on the classification and handling of excessive diagnoses. This article identifies three basic types of excessive diagnosing: too much, too mild, and too early. Correspondingly, it suggests three ways to reduce excess and advance high value care: we must stop diagnosing new phenomena, mild conditions, and early signs that do not give pain, dysfunction, and suffering.

Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review

Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).

Dediagnosing - a novel framework for making people less ill

Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions including the prescription of medicines. Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to the reduction of persons' suffering and should be introduced to make people less ill. Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation, deprescribing, decommissioning, and disinvestment. Because diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient.

Vagueness in Medicine: On Disciplinary Indistinctness, Fuzzy Phenomena, Vague Concepts, Uncertain Knowledge, and Fact-Value-Interaction

This article investigates five kinds of vagueness in medicine: disciplinary, ontological, conceptual, epistemic, and vagueness with respect to descriptive-prescriptive connections. First, medicine is a discipline with unclear borders, as it builds on a wide range of other disciplines and subjects. Second, medicine deals with many indistinct phenomena resulting in borderline cases. Third, medicine uses a variety of vague concepts, making it unclear which situations, conditions, and processes that fall under them. Fourth, medicine is based on and produces uncertain knowledge and evidence. Fifth, vagueness emerges in medicine as a result of a wide range of fact-value-interactions. The various kinds of vagueness in medicine can explain many of the basic challenges of modern medicine, such as overdiagnosis, underdiagnosis, and medicalization. Even more, it illustrates how complex and challenging the field of medicine is, but also how important contributions from the philosophy can be for the practice of medicine. By clarifying and, where possible, reducing or limiting vagueness, philosophy can help improving care. Reducing the various types of vagueness can improve clinical decision-making, informing individuals, and health policy making.

[Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]

Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.

The potential for overdiagnosis and underdiagnosis because of blood pressure variability: a comparison of the 2017 ACC/AHA, 2018 ESC/ESH and 2019 NICE hypertension guidelines

OBJECTIVE

To estimate the extent that BP measurement variability may drive over- and underdiagnosis of 'hypertension' when measurements are made according to current guidelines.

METHODS

Using data from the National Health and Nutrition Examination Survey and empirical estimates of within-person variability, we simulated annual SBP measurement sets for 1 000 000 patients over 5 years. For each measurement set, we used an average of multiple readings, as recommended by guidelines.

RESULTS

The mean true SBP for the simulated population was 118.8 mmHg with a standard deviation of 17.5 mmHg. The proportion overdiagnosed with 'hypertension' after five sets of office or nonoffice measurements using the 2017 American College of Cardiology guideline was 3-5% for people with a true SBP less than 120 mmHg, and 65-72% for people with a true SBP 120-130 mmHg. These proportions were less than 1% and 14-33% using the 2018 European Society of Hypertension and 2019 National Institute for Health and Care Excellence guidelines (true SBP <120 and 120-130 mmHg, respectively). The proportion underdiagnosed with 'hypertension' was less than 3% for people with true SBP at least 140 mmHg after one set of office or nonoffice measurements using the 2017 American College of Cardiology guideline, and less than 18% using the other two guidelines.

CONCLUSION

More people are at risk of overdiagnosis under the 2017 American College of Cardiology guideline than the other two guidelines, even if nonoffice measurements are used. Making clinical decisions about cardiovascular prediction based primarily on absolute risk, minimizes the impact of blood pressure variability on overdiagnosis.

Understanding the management of heart failure with preserved ejection fraction: a qualitative multiperspective study

BACKGROUND

About half of all people with heart failure have heart failure with preserved ejection fraction (HFpEF), in which the heart is stiff. This type of heart failure is more common in older people with a history of hypertension, obesity, and diabetes mellitus. Patients with HFpEF are often managed in primary care, sometimes in collaboration with specialists. Knowledge about how best to manage this growing population is limited, and there is a pressing need to improve care for these patients.

AIM

To explore clinicians' and patients'/carers' perspectives and experiences about the management of HFpEF to inform the development of an improved model of care.

DESIGN AND SETTING

A multiperspective qualitative study involving primary and secondary care settings across the east of England, Greater Manchester, and the West Midlands.

METHOD

Semi-structured interviews and focus groups were conducted. Transcribed data were analysed using framework analysis and informed by the normalisation process theory (NPT).

RESULTS

In total, 50 patients, nine carers/relatives, and 73 clinicians were recruited. Difficulties with diagnosis, unclear illness perceptions, and management disparity were identified as important factors that may influence management of HFpEF. The NPT construct of coherence reflected what participants expressed about the need to improve the identification, understanding, and awareness of this condition in order to improve care.

CONCLUSION

There is a pressing need to raise the public and clinical profile of HFpEF, develop a clear set of accepted practices concerning its management, and ensure that systems of care are accessible and attuned to the needs of patients with this condition.

Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation

BACKGROUND

Acute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care.

AIM

To establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI.

DESIGN & SETTING

An appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK.

METHOD

A 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria.

RESULTS

Taking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1-2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI.

CONCLUSION

Systems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.

van der Ploeg M, Floriani C, Kurpas D, Vinker S, Kreitmayer Pestic S, Petrazzuoli F, Hoffmann K, Viegas RPA, Mallen C, Tatsioni A, Maisonneuve H, Collins C, Lingner H, Tsopra R, Mueller Y, Poortvliet RKE, Gussekloo J, Streit S. Managing hypertension in frail oldest-old-The role of guideline use by general practitioners from 29 countries

Background

The best management of hypertension in frail oldest-old (≥80 years of age) remains unclear and we still lack guidelines that provide specific recommendations. Our study aims to investigate guideline use in general practitioners (GPs) and to examine if guideline use relates to different decisions when managing hypertension in frail oldest-old.

Design/Setting

Cross-sectional study among currently active GPs from 29 countries using a case-vignettes survey.

Methods

GPs participated in a survey with case-vignettes of frail oldest-olds varying in systolic blood pressure (SBP) levels and cardiovascular disease (CVD). GPs from 26 European countries and from Brazil, Israel and New Zealand were invited. We compared the percentage of GPs reporting using guidelines per country and further stratified on the most frequently mentioned guidelines. To adjust for patient characteristics (SBP, CVD and GPs’ sex, years of experience, prevalence of oldest-old and location of their practice), we used a mixed-effects regression model accounting for clustering within countries.

Results

Overall, 2,543 GPs from 29 countries were included. 59.4% of them reported to use guidelines. Higher guideline use was found in female (p = 0.031) and less-experienced GPs (p<0.001). Across countries, we found a large variation in self-reported guideline use, ranging from 25% to 90% of the GPs, but there was no difference in hypertension treatment decisions in frail oldest-old patients between GPs that did not use and GPs that used guidelines, irrespective of the guidelines they used.

Conclusion

Many GPs reported using guidelines to manage hypertension in frail oldest-old patients, however guideline users did not decide differently from non-users concerning hypertension treatment decisions. Instead of focusing on the fact if GPs use guidelines or not, we as a scientific community should put an emphasis on what guidelines suggest in frail and oldest-old patients.

Financial ties between leaders of influential US professional medical associations and industry: cross sectional study

OBJECTIVE

To investigate the nature and extent of financial relationships between leaders of influential professional medical associations in the United States and pharmaceutical and device companies.

DESIGN

Cross sectional study.

SETTING

Professional associations for the 10 costliest disease areas in the US according to the US Agency for Healthcare Research and Quality. Financial data for association leadership, 2017-19, were obtained from the Open Payments database.

POPULATION

328 leaders, such as board members, of 10 professional medical associations: American College of Cardiology, Orthopaedic Trauma Association, American Psychiatric Association, Endocrine Society, American College of Rheumatology, American Society of Clinical Oncology, American Thoracic Society, North American Spine Society, Infectious Diseases Society of America, and American College of Physicians.

MAIN OUTCOME MEASURES

Proportion of leaders with financial ties to industry in the year of leadership, the four years before and the year after board membership, and the nature and extent of these financial relationships.

RESULTS

235 of 328 leaders (72%) had financial ties to industry. Among 293 leaders who were medical doctors or doctors of osteopathy, 235 (80%) had ties. Total payments for 2017-19 leadership were almost $130m (£103m; €119m), with a median amount for each leader of $31 805 (interquartile range $1157 to $254 272). General payments, including those for consultancy and hospitality, were $24.8m and research payments were $104.6m-predominantly payments to academic institutions with association leaders named as principle investigators. Variation was great among the associations: median amounts varied from $212 for the American Psychiatric Association leaders to $518 000 for the American Society of Clinical Oncology.

CONCLUSIONS

Financial relationships between the leaders of influential US professional medical associations and industry are extensive, although with variation among the associations. The quantum of payments raises questions about independence and integrity, adding weight to calls for policy reform.

Mixed methods evaluation of workshops for citizen health advocates about financial conflicts of interests in healthcare

OBJECTIVES

To evaluate workshops delivered to citizen health advocates about financial conflicts of interest in healthcare, transparency databases which disclose industry payments in the USA and Australia and the pros and cons of advocacy groups accepting industry sponsorship.

DESIGN

Thematic analysis of workshop participant recorded discussions, and pre, post and 3-month follow-up questionnaires on confidence and knowledge about financial conflicts of interest, transparency databases and the merits of advocacy organisations accepting industry sponsorship.

PARTICIPANTS AND SETTING

48 citizen health advocates participated in a half-day workshop, held in four Australian cities, which ended with a 1-hour recorded discussion. Participants were recruited with assistance from leading state-based health advocacy organisations.

RESULTS

The thematic analysis of the recorded discussions revealed two major themes, (i) transparency and (ii) relationships with industry; and three minor themes: a lack of awareness about conflicts of interest and transparency, issues relating to trust and next steps in terms of potential reforms. In relation to transparency, participants felt strong support for transparency, strongly favouring the mandatory, extensive and accessible US Open Payments over the self-regulatory Australian model. Participants also noted that transparency had limitations, including the utility of disclosed information. In relation to industry sponsorship of advocacy groups, some participants expressed an openness to and support for accepting sponsorship, while many expressed a caution around potential downsides. Questionnaire results showed increases in both confidence and knowledge after the workshop, though only 23 of 48 participants returned the 3-month follow-up questionnaire.

CONCLUSIONS

Following a half-day workshop, citizen health advocates recruited by leading health advocacy organisations expressed strong support for tough transparency rules, and mixed feelings about advocacy groups accepting sponsorship from industry. Study limitations include a non-representative sample and a large drop-out at the 3-month post-workshop follow-up.

Defining and Evaluating Overdiagnosis in Mental Health: A Meta-Research Review

BACKGROUND

Overdiagnosis is thought to be common in some mental disorders, but it has not been defined or examined systematically. Assessing overdiagnosis in mental health requires a consistently applied definition that differentiates overdiagnosis from other problems (e.g., misdiagnosis), as well as methods for quantification.

OBJECTIVES

Our objectives were to (1) describe how the term "overdiagnosis" has been defined explicitly or implicitly in published articles on mental disorders, including usages consistent (overdefinition, overdetection) and inconsistent (misdiagnosis, false-positive test results, overtreatment, overtesting) with accepted definitions of overdiagnosis; and (2) identify examples of attempts to quantify overdiagnosis.

METHOD

We searchedPubMed through January 5, 2019. Articles on mental disorders, excluding neurocognitive disorders, were eligible if they usedthe term "overdiagnosis" in the title, abstract, or text.

RESULTS

We identified 164 eligible articles with 193 total explicit or implicit uses of the term "overdiagnosis." Of 9 articles with an explicit definition, only one provided a definition that was partially consistent with accepted definitions. Of all uses, 11.4% were consistent, and 76.7% were related to misdiagnosis and thus inconsistent. No attempts to quantify the proportion of patients who were overdiagnosed based on overdetection or overdefinition were identified.

CONCLUSIONS

There are few examples of mental health articles that describe overdiagnosis consistent with accepted definitions and no examples of quantifying overdiagnosis based on these definitions. A definition of overdiagnosis based on diagnostic criteria that include people with transient or mild symptoms not amenable to treatment (overdefinition) could be used to quantify the extent of overdiagnosis in mental disorders.

The benefits and harms of receiving a polycystic ovary syndrome diagnosis: a qualitative study of women's experiences

STUDY QUESTION

What are the benefits and harms of receiving a polycystic ovary syndrome (PCOS) diagnosis in a community sample of women, including impact on psychosocial wellbeing, lifestyle choices and behaviour?

SUMMARY ANSWER

Although some women benefit considerably from the diagnosis, such as through increased awareness and reassurance, women with minimal symptoms may experience more harm than benefit, including long-lasting anxiety and altered life plans.

WHAT IS KNOWN ALREADY

Disease labels can validate symptoms and play a vital role in understanding and coping with illness; however, they can also cause harm by evoking illness schemas about severity and permanence. Regarding PCOS, the diagnostic criteria have expanded over time to include women with milder phenotypes (such as those without signs of androgen excess). This has occurred despite limited investigation of the benefits and harms of the diagnosis and has increased the number of women diagnosed.

STUDY DESIGN SIZE DURATION

Semi-structured interviews were conducted face-to-face or by telephone with 26 participants from April-July 2018 to explore women's experiences with the diagnosis, including the benefits and harms of receiving the diagnosis and the impact on their life.

PARTICIPANTS/MATERIALS SETTING METHODS

In total, 26 women in the community self-reporting a diagnosis of PCOS (reporting mild to severe symptoms) made by a medical doctor, aged 18-45 years and living in Australia were recruited through social media. Data were analysed thematically using Framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The study identified a range of both positive and negative effects of a PCOS diagnosis in the immediate, short and long-term, which were influenced by symptom severity, expectations and experience. For women with previously unexplained and bothersome symptoms, it was a relief to receive a diagnosis, and this resulted in an increased understanding about the importance of a healthy lifestyle. By contrast, women with milder symptoms often reported feeling shocked and overwhelmed by the diagnosis, consequently experiencing anxiety about the associated long-term risks. The majority of women, regardless of symptom severity, experienced prolonged worry and anxiety about infertility, resulting for some in risk taking with contraception, unintended pregnancies, pressure to conceive early or altered life plans. With time, many women developed positive coping strategies and perceived the diagnosis to be valuable, including those who felt they had experienced minimal benefit or even harm.

LIMITATIONS REASONS FOR CAUTION

PCOS diagnosis was self-reported and the sample was highly educated.

WIDER IMPLICATIONS OF THE FINDINGS

Fear of infertility was salient for many women, underscoring the need for accurate information, counselling and reassurance of fertility potential. Given the risk of significant consequences, health professionals should use a tailored approach to PCOS diagnosis to increase the benefits of appropriate and timely diagnosis for women affected by significant symptoms, while reducing the harms of unnecessarily labelling healthy women for whom the benefits of a diagnosis are small.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.

TRIAL REGISTRATION NUMBER

N/A.

Response to diagnosis of pre-diabetes in socioeconomically deprived areas: a qualitative study

Background

Diabetes prevention is a key priority for the NHS, with a particular focus on populations at highest risk. The NHS Diabetes Prevention Programme (NHS DPP) has been introduced, offering a course of dietary and lifestyle education to individuals with pre-diabetes. However, concerns about the NHS DPP include: (1) the possible unintended consequences of labelling more people with a ‘pre-condition’; (2) the possibility of worsening health inequalities as people in socioeconomically deprived areas tend to access behaviour-change programmes less readily; (3) the appropriateness of an intervention focused on individuals versus population-wide public health policy interventions.

Aim

To explore the experience of diagnosis of pre-diabetes, and understand the barriers and facilitators to uptake of the NHS DPP for people living in socioeconomically deprived areas.

Design & setting

A qualitative study was undertaken. Participants with pre-diabetes were recruited from practices serving socioeconomically deprived areas of Sheffield, UK.

Method

Semi-structured interviews were conducted and continued until data saturation (23 participants). Thematic analysis of data was undertaken.

Results

Both healthcare context and an individual’s personal and community context shaped response to diagnosis and likelihood of engaging with the NHS DPP. Patient activation was a useful concept in understanding response. Whether or not people participated in the NHS DPP, being diagnosed with pre-diabetes tended to provoke some degree of dietary change and did not cause significant anxiety for most. However, there were multiple barriers to engaging with the NHS DPP for this patient group.

Conclusion

Diagnosing pre-diabetes can provoke an individual positive response, but the sociocultural environment often limits an individual’s ability to engage with the NHS DPP or make lifestyle change.