What Not to Do in Primary Care: Overuse of Preventive Services (Text Version)

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)

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

Slide 37. Screening should not be a faith-based initiative.

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