what not to do in primary care: overuse of preventive services

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.


Bruce N. (Ned) Calonge, M.D., M.P.H. (Chair)Diana B. Petitti, M.D., M.P.H. (Vice Chair)


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


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?”


Tip of the Iceberg


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



• 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?



• 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



• 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?


• 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


• 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


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


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


Analytic Framework on Screening for a Disease: What Evidence Do We Seek?


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


Grades of Recommendation


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


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


• 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.


• 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


• 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


Steps Forward

• The national conversation needs to change

• I think it is changing

All change is perceived as loss by someone

what not to do in primary care: overuse of preventive services

Documents

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surface early detection

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