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What Not to Do in Primary Care: Overuse of Preventive Services
The U.S. Preventive Services Task Force (USPSTF)
• Independent panel of nationally renowned, non-federal experts in primary care and evidence-based medicine
• Charged by Congress to review the scientific evidence for clinical preventive services and develop evidence-based recommendations for the health care community
University of Missouri - Columbia Family Medicine
Current USPSTF Members
Susan Curry, Ph.D.Thomas G. DeWitt, M.D.Allen J. Dietrich, M.D.Kimberly D. Gregory, M.D.,
M.P.H.David Grossman, M.D., M.P.H.George Isham, M.D., M.S.Michael LeFevre, M.D., M.S.P.H.
Rosanne Leipzig, M.D., Ph.D.Lucy N. Marion, Ph.D., R.N.Joy Melnikow, M.D., M.P.H.Bernadette Melnyk, Ph.D., R.NWanda Nicholson, M.D., M.P.H.,
M.B.AJ. Sanford (Sandy) Schwartz, M.D.Timothy Wilt, M.D., M.P.H.
University of Missouri - Columbia Family Medicine
Bruce N. (Ned) Calonge, M.D., M.P.H. (Chair)Diana B. Petitti, M.D., M.P.H. (Vice Chair)
University of Missouri - Columbia Family Medicine
AHRQ
USPSTF
EPC
Contract to synthesizeevidence
Evidencepresented
Convenes
RecommendationsAnalyticframeworkdevelopment
AHRQ staff
USPSTF officials may deny knowledge of my existence (and remove my name from the list)
USPSTF officials deny knowledge of my existence
Increased emphasis on preventive services will increase health care costs and do more harm than
good.
Prevention and Early Detection
• The national conversation seems to equate the two:– prevention = early detection
• More importantly:– early detection = prevention
Disease du jour
• If we are serious about prevention…
• Then the disease “I” care about must be detected early
EARLY DETECTIONTwo of the most expensive words in health care
EARLY DETECTION IS A NATIONAL OBSESSION
University of Missouri - Columbia Family Medicine
Early Detection: A National Obsession
• Google: August 1, 2009– Results 1 - 10 of about 7,070,000 for early
detection. (0.32 seconds)
• Google: September 9, 2009– Results 1 - 10 of about 8,210,000 for early
detection. (0.36 seconds)
• Spreading faster than swine fluUniversity of Missouri - Columbia
Family Medicine
A word about early detection
The most common response is “why not?”
University of Missouri - Columbia Family Medicine
Tip of the Iceberg
University of Missouri - Columbia Family Medicine
For all diseases, that which is clinically apparent without “looking beneath the surface” is just the tip of the iceberg.
Looking Beneath the Surface
• “Early detection” could be interpreted as a heightened awareness of those people above the surface with early manifestations of disease – I will call that case finding – and I will not address today
• But, “early detection” more often implies looking beneath the surface – I will call that screening
WHAT ARE THE SIX POSSIBLE OUTCOMES OF SCREENING?
Looking beneath the surface
Looking Beneath the Surface: Screening Outcome # 1
• Screening test negative…– but the patient has the disease - false
negative - inappropriately reassured
– Ignoring a new breast lump because mammogram was normal
University of Missouri - Columbia Family Medicine
Looking Beneath the Surface: Screening Outcome # 2
• Screening test negative and the patient does not have the disease– True negative. No health benefit since
patient does not have the disease• though patient reassured – is that always good?
– Is screening fatigue real?
University of Missouri - Columbia Family Medicine
Looking Beneath the Surface: Screening Outcome # 3
• Screening test positive…– But patient does not have disease
• false positive – subject to risks/costs of further testing and anxiety
• e.g. maternal serum testing for Down syndrome/Trisomy 18 is calibrated to label 5% of women abnormal
University of Missouri - Columbia Family Medicine
Looking Beneath the Surface: Screening Outcome # 4
• Screening test positive and patient does have disease…– but is not destined to suffer morbidity or
mortality related to the disease• treated unnecessarily• e.g. 25% of men in age range for prostate cancer
screening have prostate cancer. Life time risk of death is 3%. How many of those detected by screening are treated for disease that would never have made it to the surface?
Looking Beneath the Surface: Screening Outcome # 5
• Test positive and the patient is destined to suffer morbidity or mortality related to the disease– but outcomes of treatment in
asymptomatic stage are no different from treatment after symptoms are present• we simply lengthen the treatment time • e.g. what morbidity do we really prevent by
screening for COPD with spirometry ?University of Missouri - Columbia
Family Medicine
Looking Beneath the Surface: Screening Outcome # 6
• Test positive– Patient destined to suffer morbidity or mortality
related to the disease – and treatment in asymptomatic stage prevents complications that would develop if treatment not started until after symptoms are present
– e.g. screening for colon cancer and treating in asymptomatic stage has clearly been shown to save lives
University of Missouri - Columbia Family Medicine
Screening Outcomes: Keeping Score?
• For 5 of 6 outcomes, there can be NO health benefits to the patient– These 5 outcomes are not just costly – patients incur the harms of screening
and treatment
• For 1 of 6 outcomes, there can be health benefits to the patient, – but no assurances that the benefits will exceed the harms of screening and
treatment across screened populations
University of Missouri - Columbia Family Medicine
We should screen when good evidence demonstrates that the benefits of detection of a disease in an asymptomatic phase exceed the harms associated with diagnosis and treatment across screened populations
University of Missouri - Columbia Family Medicine
Analytic Framework on Screening for a Disease: What Evidence Do We Seek?
University of Missouri - Columbia Family Medicine
USPSTF Recommendations
• The TF judges whether the strength of the available evidence is sufficient to make a reliable assessment of the balance of benefits and harms
• If yes - then TF makes recommendation• If no - “I” (insufficient evidence) statement
– Common reasons: • Lack of evidence on clinical outcomes• Poor quality of existing studies• Good quality studies with conflicting results
University of Missouri - Columbia Family Medicine
Grades of Recommendation
University of Missouri - Columbia Family Medicine
Certainty of net benefit
Magnitude of net benefit Substantial Moderate Small Zero/Negative
High A B C D Moderate B B C D Low I – Insufficient Evidence
June 29, 2008 NY Times
“It’s incumbent on the community to dispense with the need for evidence-based medicine,” he said. “Thousands of people are dying unnecessarily.”
Cardiologist from Manhattan, NY
University of Missouri - Columbia Family Medicine
The USPSTF recommends against…
• bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery
• asymptomatic bacteriuria in men and nonpregnant women.
• chronic obstructive pulmonary disease (COPD) using spirometry
• hereditary hemochromatosis
• referral for genetic counseling or routine BRCA testing for women whose family history is not associated with an increased risk
The USPSTF recommends against…
• hepatitis B virus infection– general asymptomatic
population
• hepatitis C virus infection– asymptomatic adults who
are not at increased risk
• syphilis infection– asymptomatic persons who
are not at increased risk
• asymptomatic adolescents for idiopathic scoliosis
• elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk.
The USPSTF recommends against…
• asymptomatic carotid artery stenosis
• peripheral arterial disease
• AAA in women
• ECG, treadmill ECG or electron-beam computerized tomography (EBCT) scanning for the presence of severe coronary artery stenosis or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events
The USPSTF recommends against…
• ovarian cancer• pancreatic cancer• testicular cancer• bladder cancer • routine Pap smear screening in women who
have had a total hysterectomy for benign disease
• prostate cancer in men age 75 years or older
WE ARE SWIMMING UPSTREAM(to lay eggs and die)
THE FORCES FOR PROVIDERS TO “DO” ARE ENORMOUSLY GREATER THAN THE FORCES TO “NOT DO”
Forces To “Do”
• A noble ambition to do good, and the failure to recognize (or the ability to ignore) harm
• Miss Saigon– “So I wanted to save her, protect her
Christ, I'm American, how could I fail to do good?”– “So I wanted to save her, protect her
Christ, I'm a doctor, how could I fail to do good?”
Forces To “Do”
• A cultural expectation that medical care can only do good, not harm, and that more care is always better than less
• The public and the medical profession have faith in technology
SCREENING SHOULD NOT BE A FAITH-BASED INITIATIVE
Forces To “Do”
• The American Cancer Society
• There are disease advocacy organizations that have substantial sway over the opinions of the public and medical profession
Forces To “Do”
• Fear of litigation• “Failure to detect”
Forces To “Do”
• Quality Measures• Current PQRI quality measures include
13 specific measures that include the word “screening”
• Every one requires screening• Not one single measure addresses use
of unnecessary screening services
Forces To “Do”
• Payment• “Every dollar spent on health care is a
dollar of income for someone”• In the debates of health care reform
past (and perhaps present): it is “immoral” to pay physicians to “withhold care”
What Not to Do in Primary Care: Overuse of Preventive Services
If “Prevention” translates to unbridled use of early detection (a.k.a. screening), then
in the process of promoting prevention we will do much harm and health care costs
will increase.
Screening
We should screen when good evidence demonstrates that the benefits of detection of a disease in an asymptomatic phase exceed the harms associated with diagnosis and treatment across screened populations
University of Missouri - Columbia Family Medicine
Steps Forward
• The national conversation needs to change
• I think it is changing
All change is perceived as loss by someone
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