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Objectives The see-and-treat (S&T) approach is increasingly utilized for the treatment of cervical intraepithelial neoplasia (CIN). However, its recognition remains limited compared to the traditional three-step management. This study aims to systematically review and compare the outcomes of studies that directly assess the S&T and three-step approaches in CIN treatment. Methods A comprehensive literature search was conducted in MEDLINE, EMBASE, and the Cochrane Library up to December 10, 2024. Eligible studies directly compared the overtreatment rate, medical costs, and psychological impact of the S&T and three-step approaches for abnormal cervical smears. The inclusion criteria for women undergoing S&T had to align with those for three-step management. Data on overtreatment risk, medical costs, and psychological effects were extracted and analyzed. Comparative results were presented using forest plots, stratified by different smear categories. Results Twelve publications were included, comprising three randomized controlled trials (RCTs) and nine observational studies. Among women with ASC-H or HSIL, the overtreatment risk following S&T was comparable to that of the three-step approach (ASC-H, RR 1.40, 95% CI 0.75–2.60; HSIL, RR 0.93, 95% CI 0.71–1.23). However, in the LSIL/AS-CUS subgroup, the S&T approach was associated with a significantly higher overtreatment risk compared to the three-step method (RR 2.03, 95% CI 1.92–2.15). The S&T approach was associated with lower medical expenses for HSIL cases and a reduction in patients’ negative emotional responses compared to the three-step procedure. Conclusions The S&T approach may be a suitable alternative for women with HSIL/ASC-H smear results, considering its comparable overtreatment risk, potential cost savings, and psychological benefits. However, its use in LSIL/ASC-US cases should be carefully evaluated due to the increased risk of overtreatment.

Ductal carcinoma in situ (DCIS) accounts for 15–25% of all breast cancer diagnoses. Its prognosis is excellent overall, the main risk being the occurrence of local breast events, as most cases of DCIS do not progress to invasive cancer. Systematic screening has greatly increased the incidence of this non-obligate precursor of invasion, lending urgency to the need to identify DCIS that is prone to invasive progression and distinguish it from non-invasion-prone DCIS, as the latter can be overdiagnosed and therefore overtreated. Treatment strategies, including surgery, radiotherapy, and optional endocrine therapy, decrease the risk of local events, but have no effect on survival outcomes. Active surveillance is being evaluated as a possible new option for low-risk DCIS. Considerable efforts to decipher the biology of DCIS have led to a better understanding of the factors that determine its variable natural history. Given this variability, shared decision making regarding optimal, personalised treatment strategies is the most appropriate course of action. Well designed, risk-based de-escalation studies remain a major need in this field.

Asymptomatic bacteriuria (ASB) treatment is a common form of antibiotic overuse and diagnostic error. Antibiotic stewardship using the inappropriate diagnosis of urinary tract infection (ID-UTI) measure has reduced ASB treatment in diverse hospitals. However, critical access hospitals (CAHs) have differing resources that could impede stewardship. We aimed to determine if stewardship including the ID-UTI measure could reduce ASB treatment in CAHs. From October 2022 to July 2023, ten CAHs participated in an Intensive Quality Improvement Cohort (IQIC) program including 3 interventions to reduce ASB treatment: 1) learning labs (ie, didactics with shared learning), 2) mentoring, and 3) data-driven performance reports including hospital peer comparison based on the ID-UTI measure. To assess effectiveness of the IQIC program, change in the ID-UTI measure (ie, percentage of patients treated for a UTI who had ASB) was compared to two non-equivalent control outcomes (antibiotic duration and unjustified fluoroquinolone use). Ten CAHs abstracted a total of 608 positive urine culture cases. Over the cohort period, the percentage of patients treated for a UTI who had ASB declined (aOR per month = 0.935, 95% CI: 0.873, 1.001, = 0.055) from 28.4% (range across hospitals, 0%-63%) in the first to 18.6% (range, 0%-33%) in the final month. In contrast, antibiotic duration and unjustified fluoroquinolone use were unchanged ( = 0.768 and 0.567, respectively). The IQIC intervention, including learning labs, mentoring, and performance reports using the ID-UTI measure, was associated with a non-significant decrease in treatment of ASB, while control outcomes (duration and unjustified fluoroquinolone use) did not change.

Aims/hypothesisMore than 25% of older adults (age ≥75 years) have diabetes and may be at risk of adverse events related to treatment. The aim of this study was to assess the prevalence of intensive glycaemic control in this group, potential overtreatment among older adults and the impact of overtreatment on the risk of serious events.MethodsWe conducted a retrospective, population-based cohort study of community-dwelling older adults in Ontario using administrative data. Participants were ≥75 years of age with diagnosed diabetes treated with at least one anti-hyperglycaemic agent between 2014 and 2015. Individuals were categorised as having intensive or conservative glycaemic control (HbA1c <53 mmol/mol [<7%] or 54–69 mmol/mol [7.1–8.5%], respectively), and as undergoing treatment with high-risk (i.e. insulin, sulfonylureas) or low-risk (other) agents. We measured the composite risk of emergency department visits, hospitalisations, or death within 30 days of reaching intensive glycaemic control with high-risk agents.ResultsAmong 108,620 older adults with diagnosed diabetes in Ontario, the mean (± SD) age was 80.6 (±4.5) years, 49.7% were female, and mean (± SD) diabetes duration was 13.7 (±6.3) years. Overall, 61% of individuals were treated to intensive glycaemic control and 21.6% were treated to intensive control using high-risk agents. Using inverse probability treatment weighting with propensity scores, intensive control with high-risk agents was associated with nearly 50% increased risk of the composite outcome compared with conservative glycaemic control with low-risk agents (RR 1.49, 95% CI 1.08, 2.05).Conclusions/interpretationOur findings underscore the need to re-evaluate glycaemic targets in older adults and to reconsider the use of anti-hyperglycaemic medications that may lead to hypoglycaemia, especially in setting of intensive glycaemic control.

ContextLow-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy. Evidence AcquisitionThis mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed. Evidence SynthesisRecommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad. ConclusionClinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.

Hypothyroidism is a prevalent endocrine disorder predominantly managed in primary care. Improper treatment can lead to significant clinical and public health consequences. Despite the availability of clear clinical guidelines, over- and undertreatment frequently occur. The aim was to explore and map indications of over- and undertreatment of hypothyroidism in a primary care setting. We conducted a scoping review guided by Arksey and O'Malley. The search was conducted in PubMed, Embase, CINAHL, Scopus, and the Cochrane Library. We included peer-reviewed studies exploring over- and undertreatment of hypothyroidism in primary care and included both registry/audit and survey studies. Data were extracted across four structured stages, capturing study characteristics and treatment-related outcomes. Data on indications were compared across studies to identify recurring patterns. Nineteen studies were included. The findings show that the majority of studies with larger study populations report a moderate prevalence of over- and undertreatment. Overtreatment was associated with early initiation of therapy, absence of confirmatory testing, and suppressed TSH levels during follow-up. Undertreatment was linked to incomplete diagnostic evaluation, delayed treatment initiation, and inadequate follow-up. Survey studies reported similar patterns of inappropriate management but higher adherence to clinical guidelines. This scoping review found consistent evidence of both over- and undertreatment of hypothyroidism in primary care. A discrepancy between clinicians' reported intentions and observed practice suggests the need to attend to behavioural and organisational factors, and to provide greater support for individualised decision-making to improve care.

De-implementing inappropriate health interventions is essential for minimizing patient harm, maximizing efficient use of resources, and improving population health. Research on de-implementation has expanded in recent years as it cuts across types of interventions, patient populations, health conditions, and delivery settings. This commentary explores unique aspects of de-implementing inappropriate interventions that differentiate it from implementing evidence-based interventions, including multi-level factors, types of action, strategies for de-implementation, outcomes, and unintended negative consequences. We highlight opportunities to continue to advance research on the de-implementation of inappropriate interventions in health care and public health.