Centre for Research Excellence grants are competitive awards. They provide senior academics with resources to undertake collaborative research and to attract and support junior scholars: both PhD candidates and postdoctoral fellows. The synopsis of our NHMRC CRE grant application is below.

Novel imaging, biomarkers and genomic tests for risk assessment and early detection are emerging as major forces for change in clinical practice in Australia and internationally. While delivering valuable advances in care and benefits for patients and their families, these new and emerging diagnostics can also have important negative consequences – overdiagnosis and overtreatment – for patients and their families, clinicians and health services. This CRE will investigate how best to respond to new diagnostics, to create sustainable health care that will minimise harms induced by overdiagnosis and overtreatment, optimise health outcomes, and direct health care resources to where they are needed most.

Our multidisciplinary and innovative research will: develop a new early warning method as a prototype model for use internationally; systematically investigate the health, psycho-social, economic, and ethical impacts of new diagnostics induced by overdiagnosis and overtreatment; advance and apply novel quantitative and qualitative research methods; develop and evaluate policy responses and clinical interventions to address this emerging challenge; and work with our extensive clinical, consumer and policy networks to ensure translation of our research into policy and practice.

We will focus on cancer and cardiovascular disease because new diagnostics (advanced imaging, biomarkers and genomic tests) are already appearing in clinical use in these contexts. Furthermore these two diseases are among Australia’s largest sources of morbidity and mortality burden and health care expenditure, and, as such, are two of Australia’s health care priority areas.

Our research objectives are to:

1. Establish a novel and robust method to allow early identification of new diagnostics with significant potential for overdiagnosis and overtreatment and conduct preliminary analyses of their impact;

2. Develop and use new research methodologies to study the causes, components, frequency, impacts (physical, psychosocial and economic) and ethical challenges of overdiagnosis and overtreatment from new diagnostics across three research themes of Imaging, Biomarkers and Genomics;

3. Work with stakeholder groups to develop and test responses and interventions within each research theme which target different leverage points in the health system and are directed at clinicians, policy makers, patients and citizens;

4. Develop and use new methods to investigate and measure acceptable thresholds of: 1) health benefit:harm trade-offs for new diagnostic technologies; and 2) economic costs and opportunity costs to the healthcare system of new diagnostics. These results can be used to inform transparent policy development;

5. Translate research outcomes into policy and practice through a range of initiatives including clinical practice guidelines; stakeholder organisation engagement and activities; professional and community education; national and international collaborations; advocacy campaigns; and deliberative democracy methods.

NHMRC Program Grants are large awards that provide support for teams of high calibre researchers to pursue broad based, multi-disciplinary and collaborative research activities. Funded teams are expected to contribute to new knowledge at a leading international level in important areas of health and medical research. The synopsis of our NHMRC Program Grant application is below.

While early detection and treatment of disease brings benefits for many, there is increasing evidence of unnecessary testing and treatment, harming patients and diverting scarce resources from where they’re most needed. Yet overuse remains under-researched, and this lack of knowledge is constraining our ability to implement effective solutions.

The problem is driven by many factors including clinician concern about missing diagnoses, increasingly sophisticated diagnostic tests which detect smaller and smaller abnormalities of uncertain prognosis, and screening programs that save lives but can also “overdiagnose” disease that won‟t progress to cause harm. In addition, guideline revisions often lower the threshold for diagnosis and expand disease definitions, labelling people who have only mild symptoms or are at very low risk of illness.

Focused research efforts are needed now to address this growing global health problem, maintaining the benefits of medical advances while reducing their harms. Our proposed program has two connected research aims – 1) problem understanding, and 2) solution development and evaluation – linked with processes for translation and implementation.

AIM 1: Problem Understanding: frequency, causes, consequences
We aim to:

• Measure the prevalence, and variations in, over-diagnosis and over-treatment;

• Increase our understanding of the causes and consequences – at patient, clinician, & health system levels – of over-diagnosis and over-treatment, e.g, via document analysis, interviews, etc The prevalence and consequences will help estimate impact on individuals and the health system.

AIM 2: Solution development and testing Guided by the findings in AIM 1, we will

• Develop, pilot, and refine promising interventions from a range of potential solutions,

• Test the promising solutions in a series of multicentre randomised trials

• Apply better stratification methods to trial results to allow individualized benefit and harms (Novel solutions will include: delayed testing, eg delayed imaging for acute back pain; “community juries” to provide consumer input into screening; stepped approaches to diagnosis; and evaluating new ways to target treatment to patients with the highest potential to benefit)

The initial phase of research will investigate four exemplar conditions (cardiovascular disease; common musculoskeletal disorders such as low-back, shoulder and knee pain; prostate cancer and thyroid cancers) selected to represent common, clinically important and qualitatively distinct types of over-diagnosis and over-treatment with different origins and potential solutions. Our research in these conditions will help refine our conceptual model for how to respond to different categories of over-diagnosis and over-treatment more broadly, leading to our 3rd theme:

Translation and Implementation: Embedded in our research work is collaboration with clinical networks, policy makers, and implementers to enhance the translation of solutions with demonstrated efficacy into practice. This may include support for new diagnostic and treatment guidelines, increased shared decision making, and enhanced public input to screening policy.

Centre for Research Excellence grants are competitive awards. They provide senior academics with resources to undertake collaborative research and to attract and support junior scholars: both PhD candidates and postdoctoral fellows. The synopsis of our NHMRC CRE grant application is below.

This application proposes an Australian-led, solutions-based approach to address the global problem of medical overuse: unnecessary, ineffective and low value health care.

Our research, and the work of our international collaborators, has shown that unnecessary diagnoses and treatments (overdiagnosis and overtreatment) are a global problem, causing harm to individuals physically, psychologically and financially, and billions of dollars in waste. Most importantly, overuse leaves effective care under-utilised, and disadvantaged populations under-resourced.

Working across four institutions (Universities of Sydney, Bond, Monash and Wollongong), we will generate and test solutions to four core drivers of overuse. We will:

1. Build overuse health literacy in patients, communities and health professionals;

2. Respond to changes in screening and diagnostic technology;

3. Address financial drivers of overuse; and

4. Change clinical practices and routines.

This CRE brings together an outstanding interdisciplinary team of researchers to systematically address the key drivers of overuse. We will develop and test solutions which are grounded in stakeholder engagement, co-designed, and which connect micro, meso and macro levels of healthcare and society in a coordinated response for a more sustainable health system. We will leverage our strong existing relationships with policymakers, professional bodies, health services and consumer organisations to ensure our knowledge translation is successful.

Pandemic conditions only intensified health system pressures and the need to manage health resources wisely. Our research will tackle a problem of national and international importance to minimise harm and waste in healthcare, providing the means for effective care to be maximised and delivered equitably, so that everyone has the opportunity to benefit.