Papers by Christoffer Bjerre Haase
Sociology of Health and Illness, Dec 28, 2023
Objectives Many individual drivers for overdiagnosis have been identified. Out of those, the econ... more Objectives Many individual drivers for overdiagnosis have been identified. Out of those, the economical one has been considered the strongest with the global market of pharmaceuticals now valued at 1.000 billion U.S. dollars and is expected to grow to 1.300 billion in 2020. Despite the common awareness of the above, studies so far lack a more coherent approach explaining the structures and dynamics in society that facilitate overdiagnosis rather than examining its single driver alone. The following study offers a more comprehensive explanation to overdiagnosis, by approaching the concept with the economical point of view as the major tool. Osteoporosis, which is widely accepted as an overdiagnostic condition, is used as an example. The suggested approach opens a new possibility to identify regulations that are needed in order to reduce overdiagnosis and its undesired consequences. Method The analysis is based on abductive methodology, in which evidence about osteoporosis is contextualised into the interdisciplinary bubble theory. This economic theory explains how economical assets are being traded at prices significantly departing from their fundamental value, which constitutes a potential risk of creating a bubble. Latest well-known bubble was the financial crunch in 2008. Recently, the theory has been extrapolated to explain situations in also other fields than finance, such as scientific bubbles, political bubbles and information bubbles. The inflated value of a specific entity, due to various facilitating elements, is what these non-financial scenarios have in common with the financial bubbles. The presented study applies the facilitating elements known from bubble theory to the empirical evidence from osteoporosis. Furthermore, it evaluates the consequences of overdiagnosis in the selected case and its relevance to the other bubbles. Results Doctors, patients, pharmaceutical industry, patient associations etc. all have a stake in the use of the osteoporosis diagnosis. Therefore, they may be considered as distinct actors. The concept of speculation – profiting from trade of the asset instead of its use – correlates with the three main reasons for overdiagnosis (disease mongering, lowering thresholds and over-detection) that are all evident in the case of osteoporosis. Similarly to the financial market, the medical market for osteoporosis seems to be configured in ways to boost the use of the diagnosis. Actors in financial markets are susceptible to social influence and so it seems, in general, in the medical field. By the very definition of a bubble, it can be argued that the development of osteoporosis diagnosis can be seen as one. Conclusions Although there are many similarities, the analogy between bubbles in finance and the situation of osteoporosis as an overdiagnostic condition is not perfect. That is mainly because of insufficient solid and consistent theory of bubbles. However, the bubble theory does offer a new approach to explain overdiagnosis with a more coherent explanation than just study of individual drivers. Furthermore, this new approach shows the value of interdisciplinary research in order to understand complex phenomena such as overdiagnosis, by complementing the empirical evidence with theory from other scientific spheres.
Scandinavian Journal of Public Health, Dec 18, 2020
Aims: In three days at the beginning of the COVID-19 pandemic, the Copenhagen Emergency Medical S... more Aims: In three days at the beginning of the COVID-19 pandemic, the Copenhagen Emergency Medical Services developed a digital diagnostic device. The purpose was to assess and triage potential COVID-19 symptoms and to reduce the number of calls to public health-care helplines. The device was used almost 150,000 times in a few weeks and was described by politicians and administrators as a solution and success. However, high usage cannot serve as the sole criterion of success. What might be adequate criteria? And should digital triage for citizens by default be considered low risk? Methods: This paper reflects on the uncertain aspects of the performance, risks and issues of accountability pertaining to the digital diagnostic device in order to draw lessons for future improvements. The analysis is based on the principles of evidencebased medicine (EBM), the EU and US regulations of medical devices and the taxonomy of uncertainty in health care by Han et al. Results: Lessons for future digital devices are (a) the need for clear criteria of success, (b) the importance of awareness of other severe diseases when triaging, (c) the priority of designing the device to collect data for evaluation and (d) clear allocation of responsibilities. Conclusions: A device meant to substitute triage for citizens according to its own criteria of success should not by default be considered as low risk. In a pandemic age dependent on digitalisation, it is therefore important not to abandon the ethos of EBM, but instead to prepare the ground for new ways of building evidence of effect.
Social Studies of Science, Apr 25, 2023
People are increasingly able to generate their own health data through new technologies such as w... more People are increasingly able to generate their own health data through new technologies such as wearables and online symptom checkers. However, generating data is one thing, interpreting them another. General practitioners (GPs) are likely to be the first to help with interpretations. Policymakers in the European Union are investing heavily in infrastructures to provide GPs access to patient measurements. But there may be a disconnect between policy ambitions and the everyday practices of GPs. To investigate this, we conducted semi-structured interviews with 23 Danish GPs. According to the GPs, patients relatively rarely bring data to them. GPs mostly remember three types of patient-generated data that patients bring to them for interpretation: heart and sleep measurements from wearables and results from online symptom checkers. However, they also spoke extensively about data work with patient queries concerning measurements from the GPs’ own online Patient Reported Outcome system and online access to laboratory results. We juxtapose GP reflections on these five data types and between policy ambitions and everyday practices. These data require substantial recontextualization work before the GPs ascribe them evidential value and act on them. Even when they perceived as actionable, patient-provided data are not approached as measurements, as suggested by policy frameworks. Rather, GPs treat them as analogous to symptoms—that is to say, GPs treat patient-provided data as subjective evidence rather than authoritative measures. Drawing on Science and Technology Studies (STS) literature,we suggest that GPs must be part of the conversation with policy makers and digital entrepreneurs around when and how to integrate patient-generated data into healthcare infrastructures.
European Respiratory Journal, Sep 1, 2014
Chronic beta2-adrenoceptor activation with beta2-agonists has been shown to induce muscle hypertr... more Chronic beta2-adrenoceptor activation with beta2-agonists has been shown to induce muscle hypertrophy and modify contractile characteristics of skeletal muscles in rodents. In humans, these effects are unexplored. The purpose of the present study was to investigate the effect of four weeks of beta2-adrenoceptor activation with oral terbutaline on lean body mass and quadriceps contractile properties in active men. Eighteen men were randomly assigned in two groups (terbutaline, n=9 (TER) or placebo, n=9 (PLA)). Before and after four weeks of oral administration of 5 mg/30 kgbw terbutaline twice daily or placebo, subjects9 body composition were determined by dual X-ray absorbance. Furthermore, subjects9 VO2max and quadriceps contractile properties were measured before and after the intervention. After the intervention, lean body mass was 1.7±0.7 kg higher (P
Journal of Applied Physiology, Sep 1, 2015
Frontiers in human dynamics, Jul 8, 2021
Artificial Intelligence (AI) has the potential to greatly improve the delivery of healthcare and ... more Artificial Intelligence (AI) has the potential to greatly improve the delivery of healthcare and other services that advance population health and wellbeing. However, the use of AI in healthcare also brings potential risks that may cause unintended harm. To guide future developments in AI, the High-Level Expert Group on AI set up by the European Commission
Drug Testing and Analysis, Jun 4, 2015
The present study investigated the influence of exercise and dehydration on the urine concentrati... more The present study investigated the influence of exercise and dehydration on the urine concentrations of salbutamol after inhalation of that maximal permitted (1600 μg) on the 2015 World Anti-Doping Agency (WADA) prohibited list. Thirteen healthy males participated in the study. Urine concentrations of salbutamol were measured during three conditions: exercise (EX), exercise+deehydration (EXD), and rest (R). Exercise consisted of 75 min cycling at 60% of VO 2max and a 20-km time-trial. Fluid intake was 2300, 270, and 1100 mL during EX, EXD, and R, respectively. Urine samples of salbutamol were collected 0-24 h after drug administration. Adjustment of urine concentrations of salbutamol to a specific gravity (USG) of 1.020 g/mL was compared with no adjustment. The 2015 WADA decision limit (1200 ng/mL) for salbutamol was exceeded in 23, 31, and 10% of the urine samples during EX, EXD, and R, respectively, when unadjusted for USG. When adjusted for USG, the corresponding percentages fell to 21, 15, and 8%. During EXD, mean urine concentrations of salbutamol exceeded (1325±599 ng/mL) the decision limit 4 h after administration when unadjusted for USG. Serum salbutamol C max was lower (P<0.01) for R(3.0±0.7 ng/mL) than EX(3.8±0.8 ng/mL) and EXD(3.6±0.8 ng/mL). AUC was lower for R (14.1±2.8 ng/mL• h) than EX (16.9±2.9 ng/mL• h)(P<0.01) and EXD (16.1±3.2 ng/mL• h)(P<0.05). In conclusion, exercise and dehydration affect urine concentrations of salbutamol and increase the risk of Adverse Analytical Findings in samples collected after inhalation of that maximal permitted (1600 μg) for salbutamol. This should be taken into account when evaluating doping cases of salbutamol.
Justification and interest of the workshop A challenge with the approach of Evidence-based Medici... more Justification and interest of the workshop A challenge with the approach of Evidence-based Medicine (EBM) is the current ability to reduce but not to prevent overdiagnosis. Three different examples of this challenge will be introduced: Risk factors The case of UK’s National Institute for Health and Care Excellence updated draft guidance for the diagnosis and management of hypertension in adults. The guidance is not evidence based and will increase overdiagnosis. However, do the principles of current EBM prevent any increased health risk to become a disease as long as it is supported by evidence of a positive treatment effect? Existential conditions The case of the newly assigned ICD-10 diagnosis Sarcopenia, which is an age-related loss of muscle mass and function. Evidence supports strong associations between sarcopenia and multiple health-related conditions e.g. frailty, cardiac and respiratory diseases, cognitive impairment, low quality of life and death. However, the associations are obvious when natural parts of life have been medicalised. Does EBM prevent this? Medical screening Colorectal cancer (CRC) screening with faecal occult blood test (iFOBT) has shown a disease-specific relative mortality reduction, which could justify the CRC screening programme’s existence according to EBM. However, almost 50% of all positive screenees are (over)diagnosed with colorectal polyps. How does EBM assess the different ontology of technical measurements and phenotypical/phenomenological diseases, when the aim is to prevent diseases without medicalising any surrogate measure? Learning goals To learn about specific, clinical cases where current EBM is insufficient to prevent overdiagnosis. To learn what these cases have in common, thereby suggesting focus for future improvement of EBM. Methods The three cases will be presented, including our suggestions of reasons in EBM principles that facilitate overdiagnosis. Small group discussions will afterwards discuss: 1) other perspectives on these cases, 2) other potential cases, 3) overall principles that all cases have in common. Finally, a plenum discussion will share the thoughts and perspectives from the group discussion topics. Expected impact on the participant By sharing knowledge and experiences, participants are expected to increase their knowledge about limitations of EBM regarding overdiagnosis and stimulate new ideas and thoughts for future research projects.
European Journal of Epidemiology, Jun 1, 2021
It is with great interest we have read the article “Overdiagnosis: one concept, three perspective... more It is with great interest we have read the article “Overdiagnosis: one concept, three perspectives, and a model” by Hofmann and colleagues. We share the authors’ ambition of understanding what overdiagnosis is and what it isn’t. In our research, we define overdiagnosis on the basis of two interrelated phenomena: overdetection and overdefinition. Overdetection is the labelling of a person with a disease or abnormal condition, that would not have caused the person harm, e.g., symptoms or death, if left undiscovered. Overdefinition is the creation of new diagnoses by overmedicalising ordinary life experiences or expanding existing diagnoses by lowering thresholds or widening diagnostic criteria, without evidence of improved outcomes. These phenomena have different causes and thereby often different drivers. However, they have one important consequence in common: people are turned into patients unnecessarily, i.e., overdiagnosed. On a personal level, overdiagnosis cause various types of harms, including physical, psychological, social and financial harm. On a societal level, overdiagnosis may also cause harm to public health, cause resource waste, and cultural changes with overmedicalisation of normal life events. By definition, none of the aforementioned phenomena lead to any clinical benefit. Therefore, we disagree with Hofmann and colleagues’ definition of overdiagnosis as diagnoses that “…on balance, do more harm than good.”. We argue that introducing balance and benefits to the definition of overdiagnosis complicates the concept unnecessarily and cause problems operationalising overdiagnosis.
BMJ, Jan 13, 2022
Sarcopenia has recently been included in the international classification of diseases despite lac... more Sarcopenia has recently been included in the international classification of diseases despite lack of evidence to support essential diagnostic aspects. Christoffer Bjerre Haase and colleagues argue that the change is a step towards overdiagnosis
BMJ evidence-based medicine, Oct 25, 2019
Contributors GCR and PJG devised the concept of the manuscript. All authors provided their person... more Contributors GCR and PJG devised the concept of the manuscript. All authors provided their personal experiences of problems they have faced as early-mid career researchers and potential solutions. CW and LZJW developed problem 1; TR and BCK developed problem 2; ABD and SHB developed problem 3; CBH and GCR developed problem 4. GCR drafted the initial manuscript and all authors read, drafted and provided comments on the final manuscript. Funding The authors would like to thank the McCall MacBain Foundation for supporting the development of the Doug Altman Scholarship Competing interests GCR receives funding from the NHS National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation and the Rotary Foundation to study for a Doctor of Philosophy (DPhil) at the University of Oxford. GCR is a member of the EBMLive Steering Committee. SHB, ABD, CBH, BCK, TR, CW and LZJW were Doug Altman Scholars, presented at EBMLive 2019 and had their expenses reimbursed to travel to and attend the conference. CW is funded through the National Institute of Health grant number F30 CA243651-01. BCK has received funding from the NIHR Doctoral Research Fellowship program. PJG has received grant funding from the Canadian Paediatric Society, and the Canadian Institute of Health Research (CIHR) in the past 5 years. He is on the CMAJ Editorial Advisory Board and on the Institute Advisory Board for the CIHR Institute of Human Development, Child and Youth Health (IHDCYH) where he has expenses reimbursed to attend meetings. He is on the editorial board of BMJ Evidence Based Medicine. He is a member of the EBMLive Steering Committee, and he has expenses reimbursed to attend the conference.
npj digital medicine, Mar 18, 2022
An abundant and growing supply of digital health applications (apps) exists in the commercial tec... more An abundant and growing supply of digital health applications (apps) exists in the commercial tech-sector, which can be bewildering for clinicians, patients, and payers. A growing challenge for the health care system is therefore to facilitate the identification of safe and effective apps for health care practitioners and patients to generate the most health benefit as well as guide payer coverage decisions. Nearly all developed countries are attempting to define policy frameworks to improve decisionmaking, patient care, and health outcomes in this context. This study compares the national policy approaches currently in development/use for health apps in nine countries. We used secondary data, combined with a detailed review of policy and regulatory documents, and interviews with key individuals and experts in the field of digital health policy to collect data about implemented and planned policies and initiatives. We found that most approaches aim for centralized pipelines for health app approvals, although some countries are adding decentralized elements. While the countries studied are taking diverse paths, there is nevertheless broad, international convergence in terms of requirements in the areas of transparency, health content, interoperability, and privacy and security. The sheer number of apps on the market in most countries represents a challenge for clinicians and patients. Our analyses of the relevant policies identified challenges in areas such as reimbursement, safety, and privacy and suggest that more regulatory work is needed in the areas of operationalization, implementation and international transferability of approvals. Cross-national efforts are needed around regulation and for countries to realize the benefits of these technologies.
Preventing overdiagnosis meeting abstracts
Preventing overdiagnosis meeting abstracts
Preventing overdiagnosis meeting abstracts
Preventing overdiagnosis meeting abstracts
Preventing overdiagnosis meeting abstracts
Uploads
Papers by Christoffer Bjerre Haase