USPSTF: Perspectives USPSTF: Perspectives of a Memberof a Member

Diana Petitti, MD, MPHSeptember 7, 2008AHRQ “Lunch and Learn”

Evidence-based Evidence-based Medicine [Practice]Medicine [Practice] ““the conscientious, explicit, the conscientious, explicit,

and judicious use of current and judicious use of current best evidence in making best evidence in making decisions about the care of decisions about the care of individual patients” (Sackett individual patients” (Sackett BMJ 1996; 312: 71-72).BMJ 1996; 312: 71-72).

Evidence-based Evidence-based Medicine [Practice]Medicine [Practice] ““the attraction and the attraction and

fundamental soundness of the fundamental soundness of the core idea: that what happens core idea: that what happens to patients should be based, to patients should be based, to the greatest extent to the greatest extent possible, on evidence.” possible, on evidence.” (Eddy, Health Affairs, 2005, (Eddy, Health Affairs, 2005, 24 (1): 9-17).24 (1): 9-17).

Belief without evidence is what is Belief without evidence is what is told by one who speaks without told by one who speaks without knowledge, of things without knowledge, of things without parallel.parallel.

Ambrose BierceAmbrose Bierce

United States Preventive United States Preventive Services Task Force Services Task Force historically led the way in historically led the way in creating evidence-based creating evidence-based recommendations for the use recommendations for the use (and non-use) of preventive (and non-use) of preventive services for the United Statesservices for the United States

USPSTFUSPSTF

Independent Independent panel of experts in panel of experts in primary care and prevention; primary care and prevention; multidisciplinary; volunteersmultidisciplinary; volunteers

–Not being “owned” and/or Not being “owned” and/or perceived as “owned” is a perceived as “owned” is a major strengthmajor strength

But.....But.....

Changes in the status of Changes in the status of prevention and in the prevention and in the involvement of specialties other involvement of specialties other than primary care in prevention than primary care in prevention have substantially raised the have substantially raised the stakesstakes

The “Olden” DaysThe “Olden” Days

Colorectal cancer screeningColorectal cancer screening– The primary care physician took a stool sample in The primary care physician took a stool sample in

his/her office and tested it for occult blood using a his/her office and tested it for occult blood using a reagent he/she had in his/her “lab”reagent he/she had in his/her “lab”

– OR the primary care physician asked the patient to OR the primary care physician asked the patient to take home “stool cards” and place a specimen on take home “stool cards” and place a specimen on them and return them to the office to be testedthem and return them to the office to be tested

– If positive, they might be repeated with better prep If positive, they might be repeated with better prep or the patient would be referred to a or the patient would be referred to a gastroenterologist for further evaluation (barium gastroenterologist for further evaluation (barium enema, colonoscopy, etc.)enema, colonoscopy, etc.)

OR OR

Colorectal cancer screeningColorectal cancer screening– The primary care physician used a rigid (perish the The primary care physician used a rigid (perish the

thought) or flexible sigmoidoscope to visualize the thought) or flexible sigmoidoscope to visualize the distal colon in order to identify polyps/cancers, distal colon in order to identify polyps/cancers, which were biopsied by the physician in his/her which were biopsied by the physician in his/her office and sent to a pathologist.office and sent to a pathologist.

– If cancer was found, the patient would be referred If cancer was found, the patient would be referred to a surgeonto a surgeon

– If polyps were found, they might be removed by If polyps were found, they might be removed by the physician; more likely the patient would be the physician; more likely the patient would be referred to a gastroenterologist for a colonoscopy referred to a gastroenterologist for a colonoscopy and polyp removal.and polyp removal.

The “New Days”The “New Days”

Colorectal cancer screeningColorectal cancer screening– Primary care physiciansPrimary care physicians– RadiologistsRadiologists– GastroenterologistsGastroenterologists– GeneticistsGeneticists– Companies that make stool blood testsCompanies that make stool blood tests– Companies that make CT equipmentCompanies that make CT equipment– Companies that make tests of mutations in DNA in Companies that make tests of mutations in DNA in

stoolstool– Companies that make tests of mutations in DNA in Companies that make tests of mutations in DNA in

bloodblood– Scientists who own patents on the new technologiesScientists who own patents on the new technologies

The “New Days”The “New Days”

Patients, survivors, patients, the Patients, survivors, patients, the media, Wall Street as well as media, Wall Street as well as physicians, scientists, companies physicians, scientists, companies and the government are and the government are stakeholdersstakeholders

The “New Days”The “New Days”

Prevention has become a “high Prevention has become a “high stakes” field and the members of stakes” field and the members of the Task Force and AHRQ, which the Task Force and AHRQ, which provides major support, are “in a provides major support, are “in a fish bowl”fish bowl”

Misperceptions Misperceptions Compound the Fish Compound the Fish Bowl Bowl The TF The TF does notdoes not make make

decisions about coverage (or non-decisions about coverage (or non-coverage) for any entitycoverage) for any entity

Typical systematic review for AHRQ’s Typical systematic review for AHRQ’s EPC program costs $250,000-EPC program costs $250,000-$500,000$500,000

Insufficient evidence Insufficient evidence e.g., screening for prostate cancer using PSAe.g., screening for prostate cancer using PSA

age to end screeningage to end screeningage to start screeningage to start screeningpopulation subgroupspopulation subgroups

The Never-ending The Never-ending and/or Never to End and/or Never to End Problem Problem

What Would Make the What Would Make the Job Easier Job Easier We need more GOOD evidence We need more GOOD evidence

Not (just) more clinical trials but (good) Not (just) more clinical trials but (good) clinical trials that address pertinent clinical trials that address pertinent populationspopulations

Not more papers (how can we have 6000 Not more papers (how can we have 6000 journals and 17 million scientific journals and 17 million scientific publications per year and not know more?) publications per year and not know more?)

What Would Make the What Would Make the Job Easier Job Easier Acceptance of other type of Acceptance of other type of

evidence when clinical trials will evidence when clinical trials will not be informativenot be informativeOptimal use of observational dataOptimal use of observational dataAcceptance of decision-modelingAcceptance of decision-modeling

What Would Make the What Would Make the Job Easier Job Easier We need FEWER competing We need FEWER competing

recommendations based on the same recommendations based on the same evidenceevidence

We need to have FEWER groups involved We need to have FEWER groups involved in the recommendation business and to in the recommendation business and to have all of the groups in the business have all of the groups in the business function free of conflicts of interests function free of conflicts of interests including both financial and intellectualincluding both financial and intellectual

What Would Make the What Would Make the Job Easier Job Easier We need all stakeholders to “get on the same We need all stakeholders to “get on the same

page” concerning the purpose of medical page” concerning the purpose of medical care in general and prevention in specificcare in general and prevention in specific

To improve health and well-beingTo improve health and well-beingIn general, the purpose of involvement in medical In general, the purpose of involvement in medical care should not be to get richcare should not be to get richFor prevention, the purpose is not to save money For prevention, the purpose is not to save money that would otherwise be expended for other kinds that would otherwise be expended for other kinds of careof care

DISCUSSIONDISCUSSION