Dergi makalesi Açık Erişim

"Saving lives or harming the healthy?" Overuse and fluctuations in routine medical screening

2020    Karanfil, Ozge; Sterman, John

Tests to screen for certain diseases—for example, thyroid cancer screening, screening mammography,
and screening of high blood pressure for hypertension—are increasingly common in
medical practice. However, guidelines for routine screening are contentious for many disorders
and often fluctuate over time. Some tests are over- or underused compared to available evidence
that justifies their use, with clinical practice persistently deviating from evidence-based guidelines.
Here we develop an integrated, broad boundary feedback theory and formal model to
explain the dynamics of routine population screening including fluctuations in policy-decision
thresholds and the expansion of selection criteria which may lead to inappropriate use. We present
a behaviorally realistic, boundedly rational model of detection and selection for medical
screening that explains the potential of endogenous oscillations in practice guidelines as
decision-makers—including epidemiologists, clinicians, and patients, or policymakers from
guideline issuing organizations, perceive harms and benefits from potential outcomes and make
trade-offs between sensitivity and specificity by altering the existing guidelines and actual practice.
The model endogenously generates fluctuations in screening indications, test thresholds,
test efficiency, and the target screening population, leading to long periods during which practice
guidelines are suboptimal even if the underlying evidence base is constant. We use cancer
screening as a motivating example, but the model is generic with a wide range of potential applications
for important managerial problems in medical contexts, such as screening for hypertension,
hypercholesterolemia, autism spectrum disorder, Alzheimer’s disease, and related
dementia. It also applies to other managerial problems in nonmedical contexts, such as airport
screening, background checks, tax audits, automotive emission tests, contentious jurisdiction, or
to consumers of other kinds of information who need to make a decision—on behalf of an individual,
or for the whole population.