Advancing the Science

Mayo Clinic Medical Science Blog – an eclectic collection of research- and research education-related stories: feature stories, mini news bites, learning opportunities, profiles and more from Mayo Clinic.

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6 days ago · Nausea and vomiting: Not just a possible symptom, a dreaded reality for some

Michelle was the matriarch of a big Italian family. Her life revolved around taking care of others and her love language was food. When she was diagnosed with stage IV breast cancer, her life and family activities suddenly screeched to a halt.

Her oncologist and health care team acted quickly and put her on chemotherapy, the first line treatment.

Unfortunately, Michelle was one of the 20 percent of patients who suffer severe chemotherapy-induced nausea and vomiting, despite medicines to relieve that side effect. Those intimately familiar with nausea and vomiting say it is even worse than pain. As one patient described it, it feels as if “your muscles are being shredded apart … over and over again.” For those that suffer, it feels unrelenting, exhausting, and like there is no end in sight.

Despite the obvious misery she was experiencing, Michelle didn’t consider this side-effect to be “suffering.”  She downplayed the severity of her nausea and vomiting for fear her oncologist would take her off the chemotherapy. Michelle wanted to do anything she could to stay on the chemotherapy while it was still working to give her as much time as possible.

Michelle was restricted in her inability to see family and friends. She said, “What am I supposed to do? Puke in front of them?” By the time she was connected with her palliative care team, the adverse effects had become very severe. Despite that, they were relentless in their efforts to find a regimen that would even minimally improve her quality of life.

Aminah Jatoi, M.D.

Chemotherapy-induced nausea and vomiting research has largely focused on recent “wins,” now being able to control this for 80 percent of patients. However, the remaining 20 percent are suffering, and their story is isolating, lonely, and painful.

A research team from Mayo Clinic, led by senior author and medical oncologist, Aminah Jatoi, M.D., sought to understand the voices of this 20 percent of patients. Their study, recently published in Supportive Care in Cancer, used semi-structured interview methodology conducted by a trained physician, and qualitative analytic methods to analyze the interviews. Michelle’s story supports their findings that are broken down into two major themes:

  1. Chemotherapy-induced nausea and vomiting is severe and multidimensional, and
  2. Symptoms are underreported.

Dr. Jatoi urges, “These vivid data should motivate investigators to continue conducting clinical trials for chemotherapy-induced nausea and vomiting and should remind health care providers about the importance of patient education on the availability of therapy for breakthrough symptoms.”

She continues, “Despite advances in palliative care, a subgroup of patients continues to experience multifaceted symptoms stemming from chemotherapy-induced nausea and vomiting — sometimes with severe and far-reaching consequences. We will continue to work with patients to improve patient education. Also, promising is the better antiemetic therapy to help alleviate nausea and vomiting in the 20 percent of patients who remain symptomatic.”

According to the Journal of National Cancer Care Network, NCCN Guidelines Insights: Antiemesis, there are many treatment options for chemotherapy-induced nausea, vomiting breakthrough symptoms. If you, or a loved one, are still experiencing symptoms, speak with your care team. There is help. While we continue our research to find a cure, there is hope for an improved quality of life.

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This research was supported by the Mayo Clinic Cancer Center and Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

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Thu, Jun 28 6:00am · Let's talk about it: Death

Death. Dying. End of life care. Comfort care. Hospice. In the face of losing someone that we love whether they are young or old; hearing these words uttered and the paralyzing finality and irrevocability of it all compounds the already difficult circumstances.

These words conjure up an even more poignant sense of loss than just the life soon to end. Potentially patients and their caregivers may feel: loss of a battle, loss of hope, loss of faith, loss of the will to live, or just finally giving up. There is often a sense of guilt between patient and caregiver, feeling that we are giving up on you; or that you are giving up on us. But that is far from the truth. We say these words and discuss these feelings because we care.

Recognizing the global need for improved dialogue around end of life care, Salzburg Global Seminar convened 66 leaders from 14 countries around the topic “Rethinking Care Toward the End of Life.” The highlights from the session on end of life care, co-led by Mayo Clinic and The Dartmouth Institute for Health Policy and Clinical Practice, include a need for increased education and training for medical professionals. The goal is to find a way to have difficult conversations regarding death and smoothing the transition from a more curative notion of health care to an approach driven more by palliative care and quality of life.

Based on discussions at Salzburg Global Seminar, Session 562, an example of some of the important questions regarding end of life that may be helpful for all of us to openly discuss:

  1. Is dying well as important as living well?
  2. How have you prepared for your death?
  3. Will caring for your dying loved one bankrupt you emotionally and financially?
  4. How and what do you measure to ensure quality palliative and end of life care?
  5. Doctors, Nurses, do you want to die the way your patients die?
  6. Do you know how to access palliative care when you need it?

Let’s talk about it.

As medical professionals, as people, these are precisely the conversations that we should be having with patients, yet we struggle to clearly address death with patients and their families. We fail to find out their wishes:  how they want to spend their remaining time, what are their goals for today and also for dying. A recent study led by Mayo Clinic physician, Joe Hyder, M.D., found, “Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower [end of life] care intensity. These findings may inform patients and clinicians navigating choices around individual [end of life] care preferences.” Meaning that those that may have more familiarity with death and the dying process would actually choose less invasive medical care towards the end of their life.

A recent JAMA Internal Medicine article by another Mayo colleague, Michael Wilson, M.D., “Saving a death when you cannot save a life,” put forth an unbelievably beautiful sentiment.

These conversations are such complex topics and involve unpacking feelings, knowledge, the unknown, and understanding. Though difficult, we must ask and listen. We must change the dialogue. We have the ability to prepare patients and families for death. We may not always be able to cure you, or save your life, but we can help you die gracefully. We can help your family and friends find the ability to say goodbye, and to prepare for the unthinkable. We can facilitate discussions so that the surviving family can be at peace, knowing that their last words spoken to one another were, “I love you.”

It is indeed cliché, “in death there is sadness,” but there can be beauty and there can be peace. In health care, we have the profound opportunity to help others find that peace before it’s too late.

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Wed, May 16 8:00am · Using Big Data to Reduce Waste and Improve Care For Colorectal Cancer Patients

Colorectal cancer is the third cause of cancer deaths in the United States for both men and women. Not only is colon cancer a common cancer, a significant proportion of these patients undergo treatment. The treatment is complicated and may involve inpatient and outpatient settings as well as multiple specialists. As a result of the complex care and uncertainty as to who is overseeing their care, patients fall through the cracks and end up in the emergency department (ED) by default.

Researchers from Mayo Clinic using OptumLabs Data Warehouse, a national administrative claims database recently published a study in the Journal of Gastrointestinal Surgery. The team, led by senior author Nabil Wasif, M.D., investigated emergency department use in patients with colorectal cancer. They hoped to identify factors associated with ED visits and subsequent admission. Further, they hoped they could determine a subset of high-risk patients for which targeted interventions might reduce ED visits.

They found that over half of privately insured patients undergoing treatment for colorectal cancer visit the ED within 12 months of diagnosis. Within this group, they were able to identify common factors for a high-risk subset of patients with three or more ED visits who account for over half of all ED visits and a third of all admissions among those with colorectal cancer.

Dr. Wasif explains, “These patients could potentially be targeted with alternative management strategies in the outpatient setting.” Identifying and intervening in this high risk group has two main positive outcomes. It decreases cost to the health care system by avoiding preventable ED visits and admissions as well as improving quality of care for the patient.

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Thu, Feb 15 6:00am · The quest to understand the gluten free diet and celiac disease

Now that the holidays have wrapped up, many of us are back on the wagon of healthy living—or at least trying. We’re trying to feel our best in the sleep-deprived, not-enough-hours-in-the-day world we live in and thus we latch on to fads and diets that promise to get rid of brain fog, have more energy, and lose weight. However, these diets and fads are not always what they are cracked up to be.

One recent trend is the gluten-free diet. Gluten is a protein found in wheat, rye, and barley (think beloved carbs—bread, pastas, beer). For approximately 3 million individuals in the U.S. who have celiac disease (a serious autoimmune disease that affects the lining of the intestine), gluten must be avoided at all costs; even a tiny amount of cross-contamination can be harmful.

In recent years, reports in the media have linked gluten to all sorts of health issues ranging from feeling sluggish to the extremes of being linked to autism (debunked here). Gluten detractors claim that if you stop eating gluten you’ll feel better, have more energy, and lose weight. Some notable individuals have been eating a gluten-free diet without a clinical necessity – but is that the best course of action?

Imad Absah, M.D.

“It is important to understand that the avoidance of gluten is not without consequence,” cautions Imad Absah, M.D., a pediatric gastroenterologist at Mayo Clinic. He explains, “Many vitamins and nutrients are found in foods containing gluten, and research shows that gluten containing foods may help to lower triglycerides.” Additionally he says, “Foods that are gluten free often have added sugar and saturated fat to make the food more flavorful; the addition of sugar and fat can actually have negative consequences on other common conditions such as heart disease and diabetes.”

A health sciences researcher as well, Dr. Absah has published multiple studies looking at answering some unknown questions of celiac disease.

To assess the how widely spread unnecessary gluten avoidance may be, his team of researchers sought to determine the prevalence of gluten-free diet in youth without celiac disease. In a recent population-based study, they determined both how common a gluten-free diet seems to be, and compared that with the number of school-aged children (ages 4-18) actually diagnosed with celiac disease. The research team used a survey across six school districts in Olmsted County, Minnesota, and medical record data from the Rochester Epidemiology Project to make this comparison. The study authors report, “There are more children on a gluten-free diet than the actual cases of celiac disease in Olmsted County during the study period (school year 2014-2015).”

Dr. Absah says, “This finding could be related to an increased number of children without celiac disease who are following gluten-free diet for other indications.”

In the study, only about half of the “other indications” for following a gluten-free diet were due to “clinically indicated” reasons. These included non-celiac gluten sensitivity and wheat allergy. Of the “non-clinically indicated” group, reasons noted included: family history of celiac disease, autism, intractable epilepsy, dermatitis/eczema, and Crohn’s disease.

Dr. Absah also says, “The increase of the gluten free diet without clinical necessity is concerning; not only could some of these non-clinically indicated uses be masking symptoms of an unrelated condition that require work up, but avoiding gluten could result in other sequelae that require medical treatment.”

However, in another related study, his team found that the number of children that will require a gluten free diet due to clinical necessity is rising. The study team reported, “Both incidence and prevalence of celiac disease have continued to increase in children during the past 15 years in Olmsted County, Minnesota.”

“It is important to note that clinical and pathologic presentations of celiac disease are changing over time,” says Dr. Absah. “More non-classical and asymptomatic cases are emerging. If you are concerned about the possibility of celiac disease, it is important to talk with your physician.”

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Rochester Epidemiology Project

The Rochester Epidemiology Project is a collaboration of clinics, hospitals, and other medical facilities in Minnesota and Wisconsin and involves community members who have agreed to share their medical records for research. Using medical record information, medical scientists can discover what causes the diseases, how patients respond to medical and surgical therapies, and what will happen to patients in the future. Research studies conducted in the local community may improve the health of people both locally and globally. Learn more in the historical timeline, explore the data, or visit the website: http://rochesterproject.org.

Related Resources

Aug 8, 2017 · Proposed research agenda--Address disparities for young thyroid cancer patients

In 2013, the television show host from HGTV’s Flip or Flop, Tarek El Moussa, received a concerned email from a fan of the show. The email came from an experienced registered nurse to tell him that while watching the show she noticed a lump in the front of his throat and was extremely concerned the star may have thyroid cancer. She urged the star to see a doctor and get a thyroid biopsy. Thankfully, the star heeded her advice, as she was indeed correct and he was diagnosed with thyroid cancer that had already spread to lymph nodes. Shortly thereafter, the host underwent treatment for thyroid cancer; four years later he is in remission. At the time of diagnosis, he was 31.

According to the American Cancer Society, the most common group diagnosed with thyroid cancer is 45-54 year olds, affecting three times more women than men. Thyroid cancer accounts for 3.4 percent of all cancers and will result in about 2,010 deaths this year, and is the most common cancer in young Americans (age 16-33); the very age group in which El Moussa was at the time of diagnosis.

The high prevalence of thyroid cancer in adolescent and young adults provides the impetus for an understanding of the specific challenges this population experiences in receiving care. Researchers at Mayo Clinic, along with external collaborators, reviewed the epidemiology and challenges of thyroid cancer care among young people, and proposed a research agenda to improve their care in a recent special report in Future Oncology.

J.P. Brito Campana, M.D., M.Sc.

Senior author and endocrinologist, J.P. Brito Campana, M.D., explains, “Adolescent and young adults with thyroid cancer face challenges including overdiagnosis, reduced access to health care and inconsistent care. Successful treatment of these patients results in additional challenges, due to ongoing side effects of treatment, as well as lasting impacts on their quality of life.”

For example, inconsistent care is partially a byproduct of a shortage of pediatric endocrinologists available to care for adolescents or young adults with thyroid cancer; leading to treatment by a physician inexperienced in treating this age group. Care disparities for younger patients also can exist because this age group tends to be more financially unstable, which coupled with complex insurance barriers, can result in fragmented and expensive care. Young adults are more likely to experience bankruptcy than their counterparts without cancer due to the high cost of treatment and survivorship care. Side effects of treatment are also problematic: those that receive radiation treatment are placed at increased risk of secondary cancers such as leukemia and salivary cancer.

Given the prevalence of thyroid cancer in adolescent and young adults, one would assume that the field would be saturated with research focused on understanding this population, but Dr. Brito Campana explains, “Information about thyroid cancer in adolescent and young adults is remarkably sparse. Indeed, a literature search resulted in only 19 papers, which strongly suggests that the burden of thyroid cancer in this population has not been adequately studied.”

Dr. Brito Campana and his colleagues believe these challenges and lack of applicable research should fuel a collaborative research agenda aimed at improving the quality of care for adolescent and young adults with thyroid cancer across the spectrum of diagnosis, treatment and survivorship.

The research team urges their research colleagues to:

  • Study the impact of over and under diagnosis and factors related to increased incidence;
  • Identify socioeconomic factors and disease specific characteristics influencing access to care; and
  • Conduct effectiveness and pharmacovigilance research, promote appropriate referral and treatment, create and support a robust research infrastructure.

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Related Mayo Clinic resources:

Jun 7, 2017 · Multiple chronic conditions may be worse than previously suspected, especially for stroke patients

Are you tired of hearing about “chronic conditions” that affect every aspect of your health as well as your longevity? These difficult-to-manage diseases—some brought on by natural causes, others influenced by our behavior— interfere with our ability to enjoy life, and so we must address them. For example, coronary artery disease, congestive heart failure, high cholesterol, cancer, diabetes, cardiac arrhythmia, and arthritis are all chronic diseases. They take time, money, appointments, medications, and sometimes medical procedures, to manage; and ultimately require a change in lifestyle and adherence to suggested treatment regimen(s).

M. Yousufuddin, M.D., lead author.

Copious amounts of research have shown how these diseases shorten life expectancy. New research on the topic was recently published by researchers in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.  Led by M. Yousufuddin, M.D., a hospitalist at the Mayo Health System and Hassan Murad, M.D., preventive medicine specialist and health services researcher at Mayo Clinic, the team sought to determine the prevalence of coexisting chronic conditions in hospitalized patients who had suffered a stroke or transient ischemic attack (TIA), and the association of these conditions with 30-day mortality and readmission.

Statistics collected by the American Heart Association show that stroke is a lead cause of hospitalization, long-term disability, and death; and is closely linked with several other diseases and conditions.

The Mayo team looked at patients admitted to the hospital with a stroke or TIA, who had pre-existing heart failure, cardiac arrhythmia, coronary artery disease, cancer, or diabetes. They found that the presence of any one of these contributed to higher odds of death within 30 days. Additionally, patients with cancer, arthritis or coronary artery disease had higher odds of a readmission within 30 days.

M. Hassan Murad, M.D., senior author.

Dr. Murad says, “Our results highlight and justify the public health concern about chronic conditions.”

“In addition to treating the stroke or TIA for which the patient was admitted, health care providers need to work with their patients to quickly address and optimally manage other chronic underlying conditions,” he says. “This could prevent untimely death or readmission following a stroke or TIA.”

Does preemptive management of these conditions with life style interventions and best medical therapy reduces the mortality and morbidity of associated stroke? We don’t know for sure, but it is plausible.

We must not think that since chronic conditions are so common it is ok to be lax in their management. Nor should we believe that nothing more can be done to promote health and well-being. Rather, as patients and providers, we must work tirelessly to manage these conditions and take back control of our health and ultimately our lives.

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Apr 20, 2017 · Economies of scale: volume in health care

The concept is simple, if you perform the same procedure over and over; day in and day out, you tend to do it better, quicker, and safer than your counterpart who has only done it a few times, or infrequently. It’s referred to in other lines of work as “economies of scale.” The application of this concept dates back to Henry Ford and his novel use of this concept in the assembly line. However, unlike the assembly line with the ability to easily distinguish how many cars are generated, and the uniform safety of those cars and parts, health care still struggles to define these measures.

Researchers at the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, working with several clinical departments, have been finding that hospitals that perform the same procedure or treat the same condition repeatedly do it better than those who treat relatively few of the same condition or procedure. Increasing evidence also shows this relationship for some non-surgical therapies as well. There are better outcomes for patients, fewer complications, which translates into shorter length of stay, decreased mortality and increased survival just to name a few.

Under the direction of Sean Dowdy, M.D., a gynecologic surgeon and chair of the division of Gynecologic Surgery at Mayo Clinic, a team of researchers from Mayo Clinic’s Department of Obstetrics and Gynecology and the center studied this very issue. They published a paper in Obstetrics & Gynecology showing that despite clear guidelines to performing minimally invasive surgery for stage I-III endometrial cancer, this approach is only performed in a small portion of patients. Women are less likely to receive the accepted standard of care when performed at hospitals that treated the fewest of these patients.

Additionally, Ronald Go, M.D., a hematologist-oncologist published a paper in Cancer that showed non-Hodgkin lymphoma and a paper in the Journal of Clinical Oncology multiple myeloma patients treated at higher volume facilities may survive longer than those treated at lower volume facilities and have lower mortality, respectively.

Jeff Karnes, M.D., discussing options with a patient.

Another example of this is highlighted by the recent publication in Journal of Urology authored by Jeff Karnes, M.D., a urologic surgeon and chair of the Division of Community Urology, and other center researchers, describing the use of robots to assist in prostate cancer surgery.

The adoption of robotic-assisted radical prostatectomy (RARP) began in 2001, and gained rapid momentum as the technique of choice over the next decade, becoming the new gold standard by 2009. There is still debate around the efficacy of robot-assisted radical prostatectomy versus the pre-2009 gold standard of open radical prostatectomy. Because, while there is well-accepted evidence of the volume-outcome relationship of open radical prostatectomy, little evidence exists to show proficiency by volume results in better outcomes when conducting robot-assisted surgeries.

Dr. Karnes’ team found, “in 2011, 70% of hospitals averaged one RARP per week or less, accounting for 28% of RARPs. Compared to patients treated at the lowest quartile hospitals, those treated at the highest quartile hospitals had significantly lower rates of intraoperative complications, postoperative complications, perioperative blood transfusion, prolonged hospitalization, and mean total hospital costs.”

“Basically, we showed that larger volume hospitals and medical centers – where they are doing several a week or more – have better outcomes across this group of criteria,” says Dr. Karnes. “There is a clear dependency until a facility reaches about 100 RARPS a year, at which time further related improvement is minimal.”

“However, we also noted that a substantial proportion of RARPs are performed at low-volume hospitals,” Karnes says. “While further studies are necessary to identify additional determinants of perioperative outcomes and hospitalization costs, these results have important implications for health policy,” he states. “These types of findings seem to justify the centralization of major surgeries.”

This isn’t a new concept, but provides an ever growing body of evidence that should change thinking. The authors cite the fact that in 2002 in the United Kingdom, the National Health Services mandated radical prostatectomy be conducted only at centers that treated at least 50 such cases each year.

While the United States health care system may not be to this point, the work done by these teams is beginning to become a well-accepted fact of medicine and surgery; patients who go to a high volume center experience better outcomes. In an attempt to lower costs and make health care a free market, we must let informed patients make these crucial decisions about their care. Patients can arm themselves with this information when they are deciding on where to have a procedure. Policy makers and payers must heed this evidence and work to change the antiquated version of how we receive health care to allow patients to receive their care at these high volume centers.

Dr. Dowdy is also the Deputy Director of Practice within the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, where he works to effectively align the work of the CSHCD with the strategic priorities of the clinical practice at Mayo Clinic. Dr. Go has recently completed the Kern Health Care Delivery Scholars Program.

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Mar 7, 2017 · Choosing Wisely—At odds with Diagnostic Accuracy?

Primary Sjögren’s syndrome is a chronic autoimmune disease where your body attacks its self.  This happens because some of the white blood cells and several proteins made by these and other cells attack on normal functioning salivary glands (i.e. those in your mouth—leading to cavities, ulcers, and tooth degradation) and tear glands (i.e. your eyes).  However, the assault does not stop at just the glands; it wreaks havoc on your entire body, making you feel tired and run down. If you have Sjögren’s syndrome you also likely have painful, swollen joints that make it hard to enjoy even everyday activities. Sjögren’s can also affect the heart, lungs, brain and kidneys as well.

The diagnosis of primary Sjögren’s syndrome is not straightforward, taking an average of three years to reach a diagnosis after when symptoms started.  Patients often present with vague symptoms that could be caused by many other conditions or even side effects from common medications.

Recent, strict guidelines put forth from the American-European Consensus Group Classification Criteria are very clear on the diagnostic criteria for accurate diagnosis of primary Sjögren’s syndrome.  They include having four out of the six diagnostic criteria:

  1. Ocular symptoms – Dry eyes for more than three months, foreign-body sensation, use of tear substitutes more than three times daily
  2. Oral symptoms – Feeling of dry mouth, recurrently swollen salivary glands, frequent use of liquids to aid swallowing
  3. Ocular signs – Schirmer test performed without anesthesia (< 5 mm in 5 min), positive vital dye staining results
  4. Oral signs – Abnormal salivary scintigraphy findings, abnormal parotid sialography findings, abnormal sialometry findings (unstimulated salivary flow < 1.5 mL in 15 min)
  5. Positive minor salivary gland biopsy findings
  6. Positive anti–SSA or anti–SSB antibody results in the blood

Using data from the Rochester Epidemiology Project, Mayo Clinic researchers performed the first population based study in the United States of primary Sjögren’s syndrome to look at the prevalence of Sjögren’s syndrome in Olmsted County, Minnesota.  Out of those diagnosed with Sjögren’s, only 22 percent of patients met the diagnostic criteria put forth by the American-European Consensus Group due to the lack of certain diagnostic tests (i.e. dry eye testing, salivary gland biopsy).

In an era where we expect clinicians to be on the cutting edge of many data driven guidelines and be the protector to our limited number of resources how do clinicians come to terms with these various crusades such as Choosing Wisely™ and Diagnostic Accuracy?

Choosing Wisely refers to performing tests that provide high value at relatively low cost and eliminating expensive tests that provide low value. This could seemingly be at odds with Diagnostic Accuracy, which is the expectation for medical providers to be able to give an accurate and timely explanation for a person’s health problem.

How are clinicians meant to handle such cases?  Where does the physician’s gestalt factor in?  While guidelines help standardize care, surely physicians did not go to medical school to simply follow an algorithm.  Has the art of diagnosis been lost?

For example, one of the tests recommended for proper diagnosis of primary Sjögren’s syndrome is a lip biopsy – but physicians are not ordering this test. A lip biopsy is not without consequence and long-term implications, including the potential of a permanently numb lip.  Given this, is there a role for a physician to say, “yes, I think this is what you have—you may be sub-clinical, but I do not think it is worth the expense and complications of further testing.”

Is there harm in this assumption of diagnosis based on other less-invasive tests and observations?  Or is the harm actually performing the invasive tests?

Is there room for Choosing Wisely and Diagnostic Accuracy to meet in the middle; to allow physicians to use their clinical judgment versus ordering more tests?

Eric Matteson, M.D.

“The results of this study highlight the conceptual differences between disease diagnosis and classification criteria,” says study author Eric Matteson M.D., a rheumatologist and health sciences researcher at Mayo Clinic. “Classification criteria are tools designed specifically for clinical research. Their main objective is to guarantee that primary Sjögren’s syndrome patients included in different studies (especially clinical trials) will be similar and that a comparison of different studies will be possible.”

He cautions that classification criteria are not designed to be used as clinical tools to diagnose the disease.

“Indeed, as the results of the current study clearly show, in a real-life community setting physicians rarely use several of the tests included in classification criteria for primary Sjögren’s syndrome to diagnose the disease in individual patients, drastically decreasing the sensitivity of classification criteria,” he says.

Thus, the balance between Diagnostic Accuracy and Choosing Wisely has a tension; albeit perhaps a healthy tension.  Somewhat of a check and balance in a health care system where we try to limit low value testing, but at the same time allow physicians to apply their knowledge and experience in decision-making.  We must make progress on decreasing high cost tests and the notion of unending resources in our medical system. At the same time, we must continue to study and improve the accuracy of diagnosis, in order to more safely care for patients. But throughout this journey, carry the understanding that we live in a dynamic, colorful world; one that is not black and white (like the classification system), but full of possibilities.

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Meghan Knoedler, M.S., B.S.N, R.N.

About the Author: Meghan Knoedler, M.S., B.S.N., R.N., is a Health Services Analyst for the Center for the Science of Health Care Delivery with a policy, practice, and translation focus.

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