What Not to Do in Primary Care: Overuse of Preventive Services

1. What Not to Do in Primary Care: Overuse of Preventive Services

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 University of Missouri - Columbia Family Medicine

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. University of Missouri - Columbia Family Medicine

4. USPSTF Convenes AHRQ Recommendations Analytic framework development Evidence presented Contract to synthesize evidence EPC AHRQ staff University of Missouri - Columbia Family Medicine

5. USPSTF officials may deny knowledge of my existence (and remove my name from the list)

6. USPSTF officials deny knowledge of my existence

7. Increased emphasis on preventive services will increase health care costs and do more harm than good.

8. Prevention and Early Detection • The national conversation seems to equate the two: • prevention = early detection • More importantly: • early detection = prevention

9. Disease du jour • If we are serious about prevention… • Then the disease “I” care about must be detected early

10. Two of the most expensive words in health care Early Detection

11. Early Detection Is A National Obsession University of Missouri - Columbia Family Medicine

12. Early Detection: A National Obsession • Google: August 1, 2009 • Results 1 - 10 of about 7,070,000 for earlydetection. (0.32 seconds)  • Google: September 9, 2009 • Results 1 - 10 of about 8,210,000 for earlydetection. (0.36 seconds)  • Spreading faster than swine flu University of Missouri - Columbia Family Medicine

13. A word about early detection The most common response is “why not?” University of Missouri - Columbia Family Medicine

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. University of Missouri - Columbia Family Medicine

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

16. Looking beneath the surface What are the six possible outcomes of screening?

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 University of Missouri - Columbia Family Medicine

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? University of Missouri - Columbia Family Medicine

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 University of Missouri - Columbia Family Medicine

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?

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 ? University of Missouri - Columbia Family Medicine

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 University of Missouri - Columbia Family Medicine

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 University of Missouri - Columbia Family Medicine

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 University of Missouri - Columbia Family Medicine

25. Analytic Framework on Screening for a Disease: What Evidence Do We Seek? University of Missouri - Columbia Family Medicine

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 University of Missouri - Columbia Family Medicine

27. Grades of Recommendation University of Missouri - Columbia Family Medicine

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 University of Missouri - Columbia Family Medicine

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

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.

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

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

33. (to lay eggs and die) We are swimming upstream

34. The forces for providers to “do” are enormously greater than the forces to “not do”

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 herChrist, I'm American, how could I fail to do good?” • “So I wanted to save her, protect herChrist, I'm a doctor, how could I fail to do good?”

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

37. Screening should not be a faith-based initiative

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

39. Forces To “Do” • Fear of litigation • “Failure to detect”

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

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”

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.

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 University of Missouri - Columbia Family Medicine

44. Steps Forward • The national conversation needs to change • I think it is changing All change is perceived as loss by someone