Slide Presentation from the AHRQ 2009 Annual Conference
On September 15, 2009, Michael LeFevre made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.1 MB) (Plugin Software Help).
Slide 1
What Not to Do in Primary Care: Overuse of Preventive Services
Slide 2
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
Slide 3
Current USPSTF Members
Bruce N. (Ned) Calonge, M.D., M.P.H. (Chair)
Diana B. Petitti, M.D., M.P.H. (Vice Chair)
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.N
Wanda Nicholson, M.D., M.P.H., M.B.A
J. Sanford (Sandy) Schwartz, M.D.
Timothy Wilt, M.D., M.P.H. |
Slide 4
Graph depicting:
AHRQ
USPSTF
EPC
Contract to synthesize evidence
Evidence presented
Convenes
Recommendations
Analytic framework development
AHRQ staff
Slide 5
USPSTF officials may deny knowledge of my existence
(and remove my name from the list)
Slide 6
USPSTF officials deny knowledge of my existence
Slide 7
Increased emphasis on preventive services will increase health care costs and do more harm than good.
Slide 8
Prevention and Early Detection
- The national conversation seems to equate the two:
- prevention = early detection
- More importantly:
- early detection = prevention
Slide 9
Disease du jour
- If we are serious about prevention.
- Then the disease "I" care about must be detected early
Slide 10
Early Detection
- Two of the most expensive words in health care
Slide 11
Early Detection Is A National Obsession
Slide 12
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 flu
Slide 13
A word about early detection
The most common response is "why not?"
Slide 14
Tip of the Iceberg
For all diseases, that which is clinically apparent without "looking beneath the surface" is just the tip of the iceberg.
Slide 15
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
Slide 16
Looking Beneath the Surface
What are the six possible outcomes of screening?
Slide 17
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
Slide 18
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?
Slide 19
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
Slide 20
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?
Slide 21
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?
Slide 22
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
Slide 23
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
Slide 24
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
Slide 25
Analytic Framework on Screening for a Disease: What Evidence Do We Seek?
Slide 26
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
Slide 27
Grades of Recommendation
Slide 28
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
Slide 29
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
Slide 30
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.
Slide 31
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
Slide 32
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
Slide 33
We are swimming upstream
(to lay eggs and die)
Slide 34
The forces for providers to "do" are enormously greater than the forces to "not do"
Slide 35
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?"
Slide 36
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
Slide 37
Screening should not be a faith-based initiative
Slide 38
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
Slide 39
Forces To "Do"
- Fear of litigation
- "Failure to detect"
Slide 40
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
Slide 41
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"
Slide 42
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.
Slide 43
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
Slide 44
Steps Forward
- The national conversation needs to change
- I think it is changing
All change is perceived as loss by someone
Current as of December 2009
Internet Citation:
What Not to Do in Primary Care: Overuse of Preventive Services. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009.Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/lefevre.htm