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Dediagnosing – a novel framework for making people less ill

  • Marianne Lea
    Correspondence
    Corresponding author at: Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, PO Box 1068, Blindern, 0316 Oslo, Norway.
    Affiliations
    Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway

    Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Norway
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  • Bjørn Morten Hofmann
    Affiliations
    Department for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway

    Centre of Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway
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Open AccessPublished:August 17, 2021DOI:https://doi.org/10.1016/j.ejim.2021.07.011

      Highlights

      • Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions.
      • Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to reducing the persons’ suffering and should be introduced to make people less ill.
      • Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation and deprescribing.
      • As diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient and through shared decision making.

      Abstract

      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.

      Keywords

      The vast progress in science and technology has greatly increased the number of diseases. Today, the International Classification of Diseases (ICD-11) consists of approximately 55,000 unique codes for diseases. Together with extensive progress in treatments and increased life expectancy, more people have diseases and receive treatment for a longer time. More sensitive and predictive tests detect diseases earlier, sometimes too early, resulting in overdiagnosis and overtreatment.[
      • Hofmann B.M.
      Back to basics: overdiagnosis is about unwarranted diagnosis.
      ,
      • Hofmann B.
      Looking for trouble? Diagnostics expanding disease and producing patients.
      ] Additionally, more behaviours, experiences, and social issues are given diagnoses. All these factors increase the number of people being diagnosed and drive multimorbidity and polypharmacy.[
      • Morgan D.J.
      • Dhruva S.S.
      • Coon E.R.
      • Wright S.M.
      • Korenstein D.
      2017 update on medical overuse: a systematic review.
      ] This poses major challenges to healthcare systems on both the extension of care and the expertise required, and raises the question of whether we have gone too far in diagnosing.
      Recently, some counter-initiatives have been proposed.[
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ,
      • Moynihan R.
      • Brodersen J.
      • Heath I.
      • Johansson M.
      • Kuehlein T.
      • et al.
      Reforming disease definitions: a new primary care led, people-centred approach.
      ,
      • Marshall M.
      De-diagnosing disease.
      ] Vickers and colleagues argue “against diagnoses” and suggest replacing diagnoses with risk predictions.[
      • Vickers A.J.
      • Basch E.
      • Kattan M.W.
      Against diagnosis.
      ] To further address the problem of excessive diagnoses, we provide specific action-guiding content to the concept of dediagnosing to be used as a framework to avoid nonbeneficial diagnosing and provide appropriate care across patient populations and health care levels. We also address the implications and how dediagnosing can be used to reduce multimorbidity, polypharmacy, and to make people less ill.

      1. Diagnosing is a substantial part of healthcare

      For positive reasons, much attention goes into diagnosing. Accurate diagnosing is one of the main principles of modern medicine, sometimes even afforded with higher status than successful treatment.[
      • Goodwin J.S.
      Geriatrics and the limits of modern medicine.
      ] Moreover, patients expect and request diagnoses. As pointed out by Nuland, diagnosis is “the most critical of a physician's skills… It is every doctor's measure of his abilities; it is the most important ingredient in his professional self image.”[

      Nuland S. (2014) How we die: reflections on life's final chapter. New York, NY: Knopf; 1994, here quoted from Graber M.L., Plebani M. Diagnosis: a new era, a new journal. Diagnosis (Berl) 1: 1-2.

      ] Physicians spend much of their time in diagnosing patients. However, neither much time nor focus appears to be spent on reassessing and removing obsolete diagnoses. Diagnoses are found but rarely lost.[
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ]
      One reason why diagnosing plays such a crucial role is because the healthcare system persistently relies on formal diagnoses for healthcare attention, treatment pathways, and economic reimbursement. While diagnoses and treatments are often beneficial, recent research has increased awareness of the problem with “too much medicine”.[
      • Moynihan R.
      • Glasziou P.
      • Woloshin S.
      • Schwartz L.
      • Santa J.
      • et al.
      Winding back the harms of too much medicine.
      ,
      • Wegwarth O.
      • Gigerenzer G.
      Less is more: Overdiagnosis and overtreatment: evaluation of what physicians tell their patients about screening harms.
      ,
      • Colla C.H.
      • Morden N.E.
      • Sequist T.D.
      • Schpero W.L.
      • Rosenthal M.B.
      Choosing wisely: prevalence and correlates of low-value health care services in the United States.
      ]

      2. Diagnoses and their effects

      As diagnoses are powerful, their use warrants careful consideration. A diagnosis is defined as an identification of a bodily or mental condition, e.g., by symptoms, paraclinical signs, or markers, which are considered to be of disadvantage or harm to a person's health.[
      • Hofmann B.
      Diagnosing overdiagnosis: conceptual challenges and suggested solutions.
      ] A diagnosis labels something abnormal that should be remedied.[
      • Coon E.R.
      • Quinonez R.A.
      • Moyer V.A.
      • Schroeder A.R.
      Overdiagnosis: how our compulsion for diagnosis may be harming children.
      ] A disease or diagnosis refers to the physiological dysfunction giving rise to illness, the lived experience of an ill person.[
      • Jennings D.
      The confusion between disease and illness in clinical medicine.
      ,
      • Svenaeus F.
      Das unheimliche–towards a phenomenology of illness.
      ]
      Diagnoses warrant attention from health professionals, but are also attributed to different status and prestige. Acute and actionable diseases in specific organs located in the upper part of the body have higher status than chronic diffuse diseases related to lower parts of the body.[
      • Album D.
      • Westin S.
      Do diseases have a prestige hierarchy? A survey among physicians and medical students.
      ] Moreover, diagnoses can result in stigmatization, discrimination, and psychological burden.[
      • Weiss M.G.
      • Ramakrishna J.
      • Somma D.
      Health-related stigma: rethinking concepts and interventions.
      ] Diagnoses influence peoples’ identity construction and change the perception of a person for the person herself, their caregivers, and society. To reduce peoples’ suffering, diagnoses direct a variety of actions including treatments and doctor's appointments. Such actions affect peoples’ everyday life.[
      • Baker M.
      • Bell C.M.
      • Xiong W.
      • Etchells E.
      • Rossos P.G.
      • et al.
      Do combined pharmacist and prescriber efforts on medication reconciliation reduce postdischarge patient emergency department visits and hospital readmissions?.
      ] The management of only one single chronic disease has been described as “endless work”.[
      • Corbin J.
      Strauss A Unending work and care. 1998, here quoted from Duguay C., Gallagher F., Fortin M. The experience of adults with multimorbidity: a qualitative study.
      ] Multimorbid patients report powerlessness, worthlessness, uncertainty, and anticipation related to their health status: “Sitting on a shaky chair, not knowing whether it would collapse or stay in place” was used as a metaphor to describe his situation, by one of them.[
      • Duguay C.
      • Gallagher F.
      • Fortin M.
      The experience of adults with multimorbidity: a qualitative study.
      ] Box 1 sums up the many effects of diagnoses.
      Effects of diagnoses
      Trigger explanatory power: Explain an unwanted situation to the person and others.
      Provide attention: Warrant attention from health professionals.
      Guide actions: Direct actions (diagnostics, treatment, palliation) in healthcare to reduce peoples’ pain and suffering.
      Assign social rights: Provide access to care and sickness benefits.
      Personify: Influence people's identity constructions.
      Free from social obligations such as work (attributed by sick leave).
      Induce grounded or ungrounded anxiety: The latter because of false labels / false-positive test results.
      Apply unnecessary labels and treatment: Because of overdiagnosis; what is found will not develop into suffering.
      Imply status and prestige: Diagnosed have different status and prestige.
      Induce stigma and discrimination: Specific diagnoses can result in stigma and discrimination.
      Give a psychological and existential burden: Through stigmatization and discrimination, but also as an existential threat.
      In summary, diagnoses can be polyvalent; they can relieve and cause worries – at the same time – they can result in cure, but also unnecessary treatment and harm.[
      • Hofmann B.
      Medicalization and overdiagnosis: different but alike.
      ] While some persons fight to obtain diagnoses, others struggle to get rid of them (e.g., psychiatric diagnoses). Accordingly, we need to differentiate and remove diagnoses that do not reduce persons’ suffering, i.e., we should dediagnose to make people less ill.

      3. Dediagnosing to stop the unwarranted disease expansion

      The vast expansion of diagnoses can be explained by the multiple disease expansion illustrated in Fig. 1.[27,28] In particular, two drivers for disease expansion have gained much attention: medicalization; i.e., non medical aspects of human life made medical problems, and overdiagnosis; i.e., diagnosing a biomedical condition that in the absence of testing would not cause symptoms, disease, or death in the person's lifetime.[
      • Hofmann B.
      Diagnosing overdiagnosis: conceptual challenges and suggested solutions.
      ,
      • Hofmann B.
      Medicalization and overdiagnosis: different but alike.
      ,
      • Moynihan R.
      • Doust J.
      • Henry D.
      Preventing overdiagnosis: how to stop harming the healthy.
      ,
      • Welch H.G.
      • Schwartz L.
      • Woloshin S
      Overdiagnosed: making people sick in the pursuit of health.
      ] However, how the healthcare system is organized has not gained enough attention as a driver for diagnosing. We will argue that this may be an additional important reason for expansion included in the pragmatic expansion.
      Fig 1
      Fig. 1Seven dimensions of disease expansion. Adopted from
      [
      • Hofmann B.
      Expanding disease and undermining the ethos of medicine.
      ]
      and
      [
      • Hofmann B.
      Looking for trouble?.
      ]
      .
      Increased specialization comes together with organizational complexity to foster silo thinking, raising the number of diagnoses.[
      • Mellbye K.S.
      • Berg C.
      [Heavy consumers of drugs–seen from the viewpoint of the community pharmacist].
      ] The number of encounters tends to increase the number of diagnoses.[
      • Kaplan R.M.
      Disease, diagnoses, and dollars: facing the ever-expanding market for medical care.
      ] Seeing a specialist increases the chance of specific diagnoses. For example, seeing a pediatric allergist significantly increase the chance of being diagnosed with allergic rhinitis compared to that when seeing a pediatrician.[
      • Aung Y.N.
      • Majaesic C.
      • Senthilselvan A.
      • Mandhane P.J.
      Physician specialty influences important aspects of pediatric asthma management.
      ] Moreover, increased attention on health makes people more aware of health problems, increasing the number of encounters and diagnoses.[
      • Barsky A.J.
      The paradox of health.
      ]
      Altogether, despite the very best intentions, the way we organize the healthcare system fuels disease expansion and inflates the number of diagnoses. In our eagerness to help, we make people ill.[
      • Welch H.G.
      • Schwartz L.
      • Woloshin S
      Overdiagnosed: making people sick in the pursuit of health.
      ] However, a healthcare system making people more ill is not sustainable as it will undermine trust and demand in the long run. While a change in culture may take several years, dediagnosing is a first step toward making this a target for improvement.

      4. Why dediagnosing?

      As indicated, more healthcare does not always result in better outcomes or satisfaction with care.[
      • Fisher E.S.
      • Wennberg D.E.
      • Stukel T.A.
      • Gottlieb D.J.
      • Lucas F.L.
      • et al.
      The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.
      ,
      • Fisher E.S.
      • Wennberg D.E.
      • Stukel T.A.
      • Gottlieb D.J.
      • Lucas F.L.
      • et al.
      The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care.
      ] Some health measures have been reported to be worse in people provided with more healthcare.[
      • Fisher E.S.
      • Wennberg D.E.
      • Stukel T.A.
      • Gottlieb D.J.
      • Lucas F.L.
      • et al.
      The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.
      ] Disease labels have been associated with poorer self-related health for various diagnoses, including hypertension and thyroid disorders.[
      • Barger S.D.
      • Muldoon M.F.
      Hypertension labelling was associated with poorer self-rated health in the Third US National Health and Nutrition Examination Survey.
      ,
      • Jørgensen P.
      • Langhammer A.
      • Krokstad S.
      • Forsmo S.
      Is there an association between disease ignorance and self-rated health? The HUNT Study, a cross-sectional survey.
      ] In contrast, actual hypertensive status in terms of measured blood pressure was not associated with poor self-related health.[
      • Barger S.D.
      • Muldoon M.F.
      Hypertension labelling was associated with poorer self-rated health in the Third US National Health and Nutrition Examination Survey.
      ] It is a paradox that when becoming better, people are feeling worse.[
      • Knowles J.H.
      Doing better and feeling worse.
      ] Box 2 presents the consequences of extending diagnoses beyond what benefits people's health.
      Consequences of extending diagnoses beyond what benefits people's health.
      For the person
      Unnecessary labels, concerns, and testing
      Unnecessary treatment burden, including side-effects
      Inappropriate polypharmacy, risk of drug-drug and drug-disease interactions
      Increased use of healthcare resources and own time and resources
      For caregivers
      Unnecessary concerns
      Extra caregiver burdens
      For society
      Increased demands on the healthcare sector
      Increased need for healthcare professionals in general
      Increased need for healthcare professionals with expertise on multimorbidity and polypharmacy
      Increased financial burden
      Reduced professional integrity and trust in the healthcare services
      Another reason for diagnosis reassessment is the inevitable diagnostic uncertainty. In a recent multicenter study of patients with physician-diagnosed asthma within the past five years, a re-evaluation ruled out asthma in one-third of the patients.[
      • Aaron S.D.
      • Vandemheen K.L.
      • FitzGerald J.M.
      • Ainslie M.
      • Gupta S.
      • et al.
      Reevaluation of diagnosis in adults with physician-diagnosed asthma.
      ] Of these patients, more than 40% were objectively proven to have had asthma through documented assessments of airflow limitation at the original time of diagnosis.[
      • Aaron S.D.
      • Vandemheen K.L.
      • FitzGerald J.M.
      • Ainslie M.
      • Gupta S.
      • et al.
      Reevaluation of diagnosis in adults with physician-diagnosed asthma.
      ] Additionally, diagnostic errors are frequent and it has been estimated that most people likely will experience a minimum of one such error in their lifetime.[
      National Academies of Sciences
      Engineering, and Medicine.
      ] Table 1 sums up reasons to dediagnose.
      Table 1Reasons to dediagnose.
      ReasonComment
      MedicalizationThe condition is an ordinary life phenomenon that does not benefit persons in making it a diagnosis
      Condition is not correctDiagnostic errors, false-positive test result
      Correct diagnostics, but the condition is not a diseaseThe condition is only a risk factor, precondition, or a precursor of disease
      Unwarranted inference from “can do” to “will do”The condition is considered to be a diagnosis because we have a treatment
      Disease mongeringA condition is diagnosed because money can be earned
      The person needs helpHealthcare may not be the best institution to handle the condition (e.g., homelessness)
      Activity-generating (self-reinforcing) systemThe condition reinforces professional or system performance or justification
      Resolved conditionThe condition has resolved, and diagnosis and treatments should be removed
      Esthetic conditionThe condition only has esthetical and not functional characteristics (in the medical sense)
      Aging processThe condition is due to ordinary aging processes

      5. Introducing a framework for dediagnosing

      Diagnoses in medical records are seldom questioned which indicates the need to introduce dediagnosing. Reassessment of technologies has gained traction[
      • Noseworthy T.
      • Clement F.
      Health technology reassessment: scope, methodology, & language.
      ] and so has reviewing diagnoses and deprescribing in elderly,[
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ,
      • Moynihan R.
      • Brodersen J.
      • Heath I.
      • Johansson M.
      • Kuehlein T.
      • et al.
      Reforming disease definitions: a new primary care led, people-centred approach.
      ] but a full framework of dediagnosing has not been suggested thus far. The first step of dediagnosing constitutes verifying the diagnosis. Health records can provide an answer, but information about the tests that formed the basis for a diagnosis: how, by whom, and under what conditions rarely follows the medical record, especially not in the information flow between healthcare levels and institutions.[
      • Kripalani S.
      • LeFevre F.
      • Phillips C.O.
      • Williams M.V.
      • Basaviah P.
      • et al.
      Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
      ] If a patient's diagnosis can be verified from the medical record, re-evaluate whether the diagnosis is still relevant or valid: do present test results and guidelines still classify the person to have the diagnosis? Moreover, does the patient still have the measures, symptoms, and/or clinical changes that qualify for the diagnosis today? Both diagnostic criteria and the patient's condition can change over time. Step 2 of dediagnosing includes assessing patient preferences, assessing the actions that each diagnosis triggers, and when and how a diagnosis will benefit and harm the individual patient. Prognostic information (duration of life) can be included in this assessment. Fig. 2 presents the complete procedure for dediagnosing.
      Fig 2
      Fig. 2Procedure for dediagnosing that consists of two steps; both should be conducted. Diagnostic odysseys are explained by Black et al
      [
      • Black N.
      • Martineau F.
      • Manacorda T.
      Diagnostic odyssey for rare diseases: exploration of potential indicators.
      ]
      .
      We define dediagnosing as the removal of diagnoses that do not contribute to reducing the person's suffering, i.e., when the person is better off without it. Dediagnosing includes but goes beyond removing conditions resolved because of cure, recovery, rehabilitation, or remission (vis mediatrix naturae - the healing power of nature),[
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ] e.g., for epilepsy[
      • Fisher R.S.
      • Acevedo C.
      • Arzimanoglou A.
      • Bogacz A.
      • Cross J.H.
      • et al.
      ILAE official report: a practical clinical definition of epilepsy.
      ] and diabetes.[
      • Lean M.E.J.
      • Leslie W.S.
      • Barnes A.C.
      • Brosnahan N.
      • Thom G.
      • et al.
      Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.
      ] Dediagnosing also goes beyond reclassifying or renaming diseases, such as ductal carcinoma in situ to Indolent Lesions of Epithelial Origin.[
      • Esserman L.
      • Shieh Y.
      • Thompson I.
      Rethinking screening for breast cancer and prostate cancer.
      ,
      • Esserman L.J.
      • Varma M.
      Should we rename low risk cancers?.
      ] Moreover, it also goes beyond “diagnostic revision” and “diagnostic review,” which may focus on correcting diagnoses.
      Dediagnosing is a framework for an overall concern for persons’ health. Importantly, while there are many reasons for removing diagnoses, dediagnosing refers to the active removal of one or more diagnoses; because an overall assessment reveals that specific diagnoses are more harmful than beneficial to the person's health. To achieve success, targeting the drivers of excessive diagnosis will be crucial during the dediagnosing process. Fig. 3 provides an overview of typical drivers of diagnosis.
      Fig 3
      Fig. 3Overview of typical drivers of diagnosis. Adopted from
      [
      • Hofmann B.
      Diagnosing overdiagnosis: conceptual challenges and suggested solutions.
      ]
      .
      Multimorbid patients could undoubtedly benefit from dediagnosing. Examples of diagnoses highly relevant for dediagnosing are ADHD,[
      • Leo J.
      • Lacasse J.R.
      The New York Times and the ADHD Epidemic.
      ] hypertension,[
      • Guimarães J.M.N.
      • Griep R.H.
      • Fonseca M.J.M.
      • Duncan B.B.
      • Schmidt M.I.
      • et al.
      Four-year adiposity change and remission of hypertension: an observational evaluation from the Longitudinal Study of Adult Health (ELSA-Brasil).
      ] diabetes mellitus type 2,[
      • Lean M.E.J.
      • Leslie W.S.
      • Barnes A.C.
      • Brosnahan N.
      • Thom G.
      • et al.
      Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.
      ] chronic pain conditions,[
      • Marshall B.
      • Bland M.K.
      • Hulla R.
      • Gatchel R.J
      Considerations in addressing the opioid epidemic and chronic pain within the USA.
      ] fibrous histiocytoma, haemangiopericytoma,[
      • CHAN J.K.C.
      Solitary fibrous tumour — everywhere, and a diagnosis in vogue.
      ] PMS,[
      • Reilly J.
      • Kremer J.
      PMS: Moods, measurements and interpretations.
      ] and resignation syndrome.[
      • Sallin K.
      • Lagercrantz H.
      • Evers K.
      • Engström I.
      • Hjern A.
      • et al.
      Resignation Syndrome: Catatonia? Culture-bound?.
      ] Table 2 shows examples of dediagnosing.
      Table 2Three examples of dediagnosing.
      Example 1Example 2Example 3
      Patient descriptionBoy, 20 years old, diagnosed with ADHD in his childhood.Woman, 56 years old, diagnosed with diabetes mellitus type 2 four years ago.Woman 94 years old, diagnosed with osteoporosis decades ago.
      DediagnosingStep 1As a 20-year-old, he has no ongoing symptoms that would indicate ADHD. The ADHD diagnosis is not valid anymore.Since the time of diagnosis, she has started exercising, improved her diet and lost weight. HbA1c has now dropped to <6.5% without antidiabetic drugs. The diabetes mellitus type 2 diagnosis is not valid anymore.The diagnostic criterion is still present since the woman has experienced several osteoporotic fractures.
      Step 2a) The boy prefers not to have the ADHD diagnosis anymore.

      b) The ADHD diagnosis trigger special attention regarding the driver's license and stigmatizes.

      c) The ADHD diagnosis is considered not to be beneficial for the boy, but rather to harm him, see points 2a and 2b.

      a) The woman prefers not to have the diabetes mellitus diagnosis anymore. She thinks the diagnosis is stigmatizing.

      b) The diabetes mellitus diagnosis can trigger prescription of drugs, however, the woman does not need such drugs anymore. The diagnosis also triggers stigmatization.

      c) The diabetes mellitus diagnosis is considered to harm the patient due to stigmatization.
      a) The woman express worries and uncertainty as a result of the osteoporosis diagnosis and the accompanying risk of fractures.

      b) The osteoporosis diagnosis triggers prescription of non-osteoporotic drugs. However, since life expectancy is considered to be short, non-osteoporotic drugs are deprescribed now.

      c) The osteoporosis diagnosis is considered to harm the woman due to worries about the risk of fractures.
      ConclusionADHD can be dediagnosed.Diabetes mellitus type 2 can be dediagnosed.Osteoporosis can be dediagnosed.

      6. Dediagnosing supporting other measures to reduce overuse

      Dediagnosing comes together with other efforts to reduce overuse as shown in Box 3.[
      • Scott I.A.
      • Hilmer S.N.
      • Reeve E.
      • Potter K.
      • Le Couteur D.
      • et al.
      Reducing inappropriate polypharmacy: the process of deprescribing.
      ,
      • Wolf E.R.
      • Krist A.H.
      • Schroeder A.R.
      Deimplementation in pediatrics: past, present, and future.
      ,
      • Williams I.
      • Harlock J.
      • Robert G.
      • Mannion R.
      • Brearley S.
      • et al.
      Health Services and Delivery Research. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study.
      ,
      • Orso M.
      • de Waure C.
      • Abraha I.
      • Nicastro C.
      • Cozzolino F.
      • et al.
      Health technology disinvestment worldwide: overview of programs and possible determinants.
      ,
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ,
      • Moynihan R.
      • Brodersen J.
      • Heath I.
      • Johansson M.
      • Kuehlein T.
      • et al.
      Reforming disease definitions: a new primary care led, people-centred approach.
      ,
      • Sawan M.
      • Reeve E.
      • Turner J.
      • Todd A.
      • Steinman M.A.
      • et al.
      A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review.
      ,
      • Sistrom C.L.
      The ACR appropriateness criteria: translation to practice and research.
      ] Health professionals especially engaged in reducing inappropriate drug therapy are typically generalists, including geriatricians,[
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ] pharmacists, and general practitioners. It has been suggested that “the management of polypharmacy could be seen as a new type of specialism”.[
      • Brad L.
      • Howard C.
      • Williams S.
      Time and pharmacist support in general practice are needed to improve medicines optimisation.
      ] However, to move even closer toward the goal of reducing overuse, specialists must also get themselves involved in the process. They will undoubtedly be highly competent to dediagnose within their area of expertise. Therefore, introducing dediagnosing may increase specialists’ participation and contribution to the common overall objective of reducing illness, and not just entrust this task to generalists.
      Examples of measures to reduce overuse
      Dediagnosing – “the removal of diagnoses that do not contribute to reducing the person's suffering” (Lea and Hofmann 2021).
      Deimplementation – “the process of reducing care that is harmful, ineffective, overused, or not cost-effective” [
      • Wolf E.R.
      • Krist A.H.
      • Schroeder A.R.
      Deimplementation in pediatrics: past, present, and future.
      ].
      Deprescribing – “the process of withdrawal or dose reduction of a medication which is considered inappropriate in an individual” [
      • Sawan M.
      • Reeve E.
      • Turner J.
      • Todd A.
      • Steinman M.A.
      • et al.
      A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review.
      ].
      Decommissioning – “the planned process of removing, reducing, or replacing health care services” [
      • Williams I.
      • Harlock J.
      • Robert G.
      • Mannion R.
      • Brearley S.
      • et al.
      Health Services and Delivery Research. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study.
      ].
      Disinvestment –“the process of (partially or completely) withdrawing health resources from any existing healthcare practices, procedures, technologies, or pharmaceuticals that are deemed to deliver little or no health gain for their cost, and thus, are not efficient health resource allocation” [
      • Orso M.
      • de Waure C.
      • Abraha I.
      • Nicastro C.
      • Cozzolino F.
      • et al.
      Health technology disinvestment worldwide: overview of programs and possible determinants.
      ,
      • Elshaug A.G.
      • Hiller J.E.
      • Tunis S.R.
      • Moss J.R.
      Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices.
      ].
      Diagnosis Review – A review carried out by a family doctor for persons with multiple morbidities to reduce unneeded labels and treatments [
      • Moynihan R.
      • Brodersen J.
      • Heath I.
      • Johansson M.
      • Kuehlein T.
      • et al.
      Reforming disease definitions: a new primary care led, people-centred approach.
      ].
      Avoid inappropriate diagnosing – Avoiding inappropriate imaging and non-indicated diagnostics, e.g., by sticking to acknowledged appropriateness criteria [
      • Sistrom C.L.
      The ACR appropriateness criteria: translation to practice and research.
      ].
      ERASE – “Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines”. A primary care led approach for undiagnosing in the elderly [
      • Page A.
      • Etherton-Beer C.
      Undiagnosing to prevent overprescribing.
      ].
      Little research has been conducted on patients’ eventual psychological sequelae from discontinuation of long-term treatment. This should be considered when dediagnosing or deprescribing is considered. Patients’ potential perceptions have been suggested[
      • Stevenson J.
      • Abernethy A.P.
      • Miller C.
      • Currow D.C.
      Managing comorbidities in patients at the end of life.
      ] to be the following:
      • “I was told to take this until I die. Are you saying I'm about to die?”
      • “But won't I get sick without the tablet?”
      • “But my other doctor told me I should never stop this drug. Are you saying (s)he was wrong? Do you know what you're doing?”
      Starting with dediagnosing, ahead of deprescribing, may make it easier to understand and accept the process for the patient. If a diagnosis is not present anymore, it must be indisputable and obvious that no further treatment is required. In this manner, dediagnosing combined with deprescribing may lead to less uncertainty for patients.

      7. Moving forward

      From elaborating the framework and procedure to applying dediagnosing, we must move to active and effective implementation. Moreover, we need to dediagnose in close collaboration with the affected person, taking the person’s perspectives, needs, preferences, and interests into consideration through shared decision making. Dediagnosing may not be expedient for all individuals or in all circumstances. For instance, “cancer survivors” may be cured, but still experience many related ailments.[
      • Madan-Swain A.
      • Brown R.T.
      • Foster M.A.
      • Vega R.
      • Byars K.
      • et al.
      Identity in adolescent survivors of childhood cancer.
      ] Importantly, the removal of a diagnosis through dediagnosing is independent of future disease recurrence risk. Here, we distinguish between diagnosis, disease, or illness on one side and vulnerability or future risk of disease recurrence on the other. The purpose of dediagnosing is simply to bring diagnoses on par with suffering, and thereby to reduce unnecessary illness. Diagnostics should be less directed by how good we are at identifying and treating specific conditions and more by whether doing so is helpful to people. Hence, shifting from diagnostic reasoning to management reasoning [
      • Cook D.A.
      • Sherbino J.
      • Durning S.J.
      Management reasoning: beyond the diagnosis.
      ] is helpful for dediagnosing.
      The presented novel framework of dediagnosing is based on insights from the philosophy of medicine, ethics, and epidemiology along with extensive clinical experience. It comes together with other efforts to reduce overuse and is directed toward relevant stakeholders in a routine clinical context. We need dediagnosing to remove diagnoses that do not reduce persons’ suffering and to make them less ill.

      8. Contributors and sources

      Author ML has many years of experience as a clinical pharmacist working in hospital wards, conducting medicine reviews, including deprescribing, as one of the work tasks. She has a PhD in clinical pharmacy from 2019. Author BMH is a professor in philosophy of medicine and ethics and has worked extensively with fundamental issues and concepts in health care, such as disease, diagnosis, futility, and overdiagnosis. ML had the idea of the article and made the first draft. Both authors have contributed substantially to the content of the article and several revisions. ML has made Box 2 and 3, Table 2 and Fig. 2, while BMH has made Box 1, Table 1, and Figs. 1 and 3. The final version of the article has been approved by both authors and both are guarantors of the article.

      Declaration of Competing Interest

      We certify that there is no actual or potential conflict of interest in relation to this study, and there are no financial arrangements or arrangements with respect to the content of this viewpoint with any companies or organizations.

      Acknowledgments

      We are most thankful to several anonymous clinicians whose wise comments have contributed to the improvement of the article.

      Patient involvement

      We are most thankful to members of two patient organisations who have generously provided comments and important viewpoints.

      Data sharing statement

      All data are available in the paper.

      References

        • Scott I.A.
        • Hilmer S.N.
        • Reeve E.
        • Potter K.
        • Le Couteur D.
        • et al.
        Reducing inappropriate polypharmacy: the process of deprescribing.
        JAMA Intern. Med. 2015; 175: 827-834
        • Wolf E.R.
        • Krist A.H.
        • Schroeder A.R.
        Deimplementation in pediatrics: past, present, and future.
        JAMA Pediatrics. 2021; 175 (Mar 1): 230-232https://doi.org/10.1001/jamapediatrics.2020.4681
        • Williams I.
        • Harlock J.
        • Robert G.
        • Mannion R.
        • Brearley S.
        • et al.
        Health Services and Delivery Research. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study.
        Health Serv Deliv Res. 2017; 5 (https://doi.org/10.3310/hsdr05220)
        • Orso M.
        • de Waure C.
        • Abraha I.
        • Nicastro C.
        • Cozzolino F.
        • et al.
        Health technology disinvestment worldwide: overview of programs and possible determinants.
        Int J Technol Assess Health Care. 2017; 33: 239-250
        • Hofmann B.M.
        Back to basics: overdiagnosis is about unwarranted diagnosis.
        Am J Epidemiol. 2019; 188: 1812-1817
        • Hofmann B.
        Looking for trouble? Diagnostics expanding disease and producing patients.
        J Eval Clin Pract. 2018; 24: 978-982
        • Morgan D.J.
        • Dhruva S.S.
        • Coon E.R.
        • Wright S.M.
        • Korenstein D.
        2017 update on medical overuse: a systematic review.
        JAMA Intern. Med. 2018; 178: 110-115
        • Page A.
        • Etherton-Beer C.
        Undiagnosing to prevent overprescribing.
        Maturitas. 2019; 123: 67-72
        • Moynihan R.
        • Brodersen J.
        • Heath I.
        • Johansson M.
        • Kuehlein T.
        • et al.
        Reforming disease definitions: a new primary care led, people-centred approach.
        BMJ Evid-Based Med. 2019; 24: 170-173
        • Marshall M.
        De-diagnosing disease.
        BMJ. 2019; 365 (May 9; PMID: 31072873): 12044https://doi.org/10.1136/bmj.l2044
        • Vickers A.J.
        • Basch E.
        • Kattan M.W.
        Against diagnosis.
        Ann Intern Med. 2008; 149: 200-203
        • Goodwin J.S.
        Geriatrics and the limits of modern medicine.
        N Engl J Med. 1999; 340: 1283-1285
      1. Nuland S. (2014) How we die: reflections on life's final chapter. New York, NY: Knopf; 1994, here quoted from Graber M.L., Plebani M. Diagnosis: a new era, a new journal. Diagnosis (Berl) 1: 1-2.

        • Moynihan R.
        • Glasziou P.
        • Woloshin S.
        • Schwartz L.
        • Santa J.
        • et al.
        Winding back the harms of too much medicine.
        BMJ. 2013; 346: f1271
        • Wegwarth O.
        • Gigerenzer G.
        Less is more: Overdiagnosis and overtreatment: evaluation of what physicians tell their patients about screening harms.
        JAMA Intern. Med. 2013; 173: 2086-2087
        • Colla C.H.
        • Morden N.E.
        • Sequist T.D.
        • Schpero W.L.
        • Rosenthal M.B.
        Choosing wisely: prevalence and correlates of low-value health care services in the United States.
        J Gen Intern Med. 2014;
        • Hofmann B.
        Diagnosing overdiagnosis: conceptual challenges and suggested solutions.
        Eur J Epidemiol. 2014; 29: 599-604
        • Coon E.R.
        • Quinonez R.A.
        • Moyer V.A.
        • Schroeder A.R.
        Overdiagnosis: how our compulsion for diagnosis may be harming children.
        Pediatrics. 2014; 134: 1013-1023
        • Jennings D.
        The confusion between disease and illness in clinical medicine.
        CMAJ. 1986; 135: 865-870
        • Svenaeus F.
        Das unheimliche–towards a phenomenology of illness.
        Med Health Care Philos. 2000; 3: 3-16
        • Album D.
        • Westin S.
        Do diseases have a prestige hierarchy? A survey among physicians and medical students.
        Soc Sci Med. 2008; 66: 182-188
        • Weiss M.G.
        • Ramakrishna J.
        • Somma D.
        Health-related stigma: rethinking concepts and interventions.
        Psychol Health Medicine. 2006; 11: 277-287
        • Baker M.
        • Bell C.M.
        • Xiong W.
        • Etchells E.
        • Rossos P.G.
        • et al.
        Do combined pharmacist and prescriber efforts on medication reconciliation reduce postdischarge patient emergency department visits and hospital readmissions?.
        J Hospital Med. 2018; 13: 152-157
        • Corbin J.
        Strauss A Unending work and care. 1998, here quoted from Duguay C., Gallagher F., Fortin M. The experience of adults with multimorbidity: a qualitative study.
        J Comorb. 2014; 4: 11-21
        • Duguay C.
        • Gallagher F.
        • Fortin M.
        The experience of adults with multimorbidity: a qualitative study.
        J Comorb. 2014; 4: 11-21
        • Hofmann B.
        Medicalization and overdiagnosis: different but alike.
        Med Health Care Philos. 2016; 19: 253-264
        • Hofmann B.
        Expanding disease and undermining the ethos of medicine.
        Eur J Epidemiol. 2019; 34: 613-619
        • Hofmann B.
        Looking for trouble?.
        Diagnostics Expand Dis Produc Patients. 2018; 24: 978-982
        • Moynihan R.
        • Doust J.
        • Henry D.
        Preventing overdiagnosis: how to stop harming the healthy.
        BMJ. 2012; 344: e3502
        • Welch H.G.
        • Schwartz L.
        • Woloshin S
        Overdiagnosed: making people sick in the pursuit of health.
        Beacon Press, Boston2011
        • Mellbye K.S.
        • Berg C.
        [Heavy consumers of drugs–seen from the viewpoint of the community pharmacist].
        Tidsskr Nor Laegeforen. 2004; 124: 3069-3071
        • Kaplan R.M.
        Disease, diagnoses, and dollars: facing the ever-expanding market for medical care.
        Springer Science & Business Media, 2009
        • Aung Y.N.
        • Majaesic C.
        • Senthilselvan A.
        • Mandhane P.J.
        Physician specialty influences important aspects of pediatric asthma management.
        J Allergy Clin Immunol Pract. 2014; 2 (e305): 306-312
        • Barsky A.J.
        The paradox of health.
        N Engl J Med. 1988; 318: 414-418
        • Fisher E.S.
        • Wennberg D.E.
        • Stukel T.A.
        • Gottlieb D.J.
        • Lucas F.L.
        • et al.
        The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.
        Ann Intern Med. 2003; 138: 288-298
        • Fisher E.S.
        • Wennberg D.E.
        • Stukel T.A.
        • Gottlieb D.J.
        • Lucas F.L.
        • et al.
        The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care.
        Ann Intern Med. 2003; 138: 273-287
        • Barger S.D.
        • Muldoon M.F.
        Hypertension labelling was associated with poorer self-rated health in the Third US National Health and Nutrition Examination Survey.
        J Hum Hypertens. 2006; 20: 117-123
        • Jørgensen P.
        • Langhammer A.
        • Krokstad S.
        • Forsmo S.
        Is there an association between disease ignorance and self-rated health? The HUNT Study, a cross-sectional survey.
        BMJ Open. 2014; 4e004962
        • Knowles J.H.
        Doing better and feeling worse.
        Bull Am Acad Arts Sci. 1978; : 26-38
        • Aaron S.D.
        • Vandemheen K.L.
        • FitzGerald J.M.
        • Ainslie M.
        • Gupta S.
        • et al.
        Reevaluation of diagnosis in adults with physician-diagnosed asthma.
        JAMA. 2017; 317: 269-279
        • National Academies of Sciences
        Engineering, and Medicine.
        Improving diagnosis in health care. The National Academies Press, Washington, DC2015https://doi.org/10.17226/21794
        • Noseworthy T.
        • Clement F.
        Health technology reassessment: scope, methodology, & language.
        Int J Technol Assess Health Care. 2012; 28: 201-202
        • Kripalani S.
        • LeFevre F.
        • Phillips C.O.
        • Williams M.V.
        • Basaviah P.
        • et al.
        Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
        JAMA. 2007; 297: 831-841
        • Black N.
        • Martineau F.
        • Manacorda T.
        Diagnostic odyssey for rare diseases: exploration of potential indicators.
        Policy Innovation Research Unit (PIRU), 2015
        • Fisher R.S.
        • Acevedo C.
        • Arzimanoglou A.
        • Bogacz A.
        • Cross J.H.
        • et al.
        ILAE official report: a practical clinical definition of epilepsy.
        Epilepsia. 2014; 55: 475-482
        • Lean M.E.J.
        • Leslie W.S.
        • Barnes A.C.
        • Brosnahan N.
        • Thom G.
        • et al.
        Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.
        Lancet. 2018; 391: 541-551
        • Esserman L.
        • Shieh Y.
        • Thompson I.
        Rethinking screening for breast cancer and prostate cancer.
        JAMA. 2009; 302: 1685-1692
        • Esserman L.J.
        • Varma M.
        Should we rename low risk cancers?.
        BMJ. 2019; 364: k4699
        • Leo J.
        • Lacasse J.R.
        The New York Times and the ADHD Epidemic.
        Society. 2015; 52: 3-8
        • Guimarães J.M.N.
        • Griep R.H.
        • Fonseca M.J.M.
        • Duncan B.B.
        • Schmidt M.I.
        • et al.
        Four-year adiposity change and remission of hypertension: an observational evaluation from the Longitudinal Study of Adult Health (ELSA-Brasil).
        J Hum Hypertens. 2020; 34: 68-75
        • Marshall B.
        • Bland M.K.
        • Hulla R.
        • Gatchel R.J
        Considerations in addressing the opioid epidemic and chronic pain within the USA.
        Pain Manag. 2019; 9: 131-138
        • CHAN J.K.C.
        Solitary fibrous tumour — everywhere, and a diagnosis in vogue.
        Histopathology. 1997; 31: 568-576
        • Reilly J.
        • Kremer J.
        PMS: Moods, measurements and interpretations.
        Irish J Psychol. 2001; 22: 22-37
        • Sallin K.
        • Lagercrantz H.
        • Evers K.
        • Engström I.
        • Hjern A.
        • et al.
        Resignation Syndrome: Catatonia? Culture-bound?.
        Front Behav Neurosci. 2016; 10 (Published 2016 Jan 29): 7https://doi.org/10.3389/fnbeh.2016.00007
        • Sawan M.
        • Reeve E.
        • Turner J.
        • Todd A.
        • Steinman M.A.
        • et al.
        A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review.
        Expert Rev Clin Pharmacol. 2020; 13: 233-245
        • Sistrom C.L.
        The ACR appropriateness criteria: translation to practice and research.
        J Am Coll Radiol. 2005; 2: 61-67
        • Brad L.
        • Howard C.
        • Williams S.
        Time and pharmacist support in general practice are needed to improve medicines optimisation.
        BMJ Opin. 2018;
        • Elshaug A.G.
        • Hiller J.E.
        • Tunis S.R.
        • Moss J.R.
        Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices.
        Aust New Zeal Health Policy. 2007; 4: 23
        • Stevenson J.
        • Abernethy A.P.
        • Miller C.
        • Currow D.C.
        Managing comorbidities in patients at the end of life.
        BMJ. 2004; 329: 909-912
        • Madan-Swain A.
        • Brown R.T.
        • Foster M.A.
        • Vega R.
        • Byars K.
        • et al.
        Identity in adolescent survivors of childhood cancer.
        J Pediatr Psychol. 2000; 25: 105-115
        • Cook D.A.
        • Sherbino J.
        • Durning S.J.
        Management reasoning: beyond the diagnosis.
        JAMA. 2018; 319: 2267-2268