Thursday, August 18, 2011

Mammograms and death panels: why the Preventive Services Task Force keeps pulling its punches

Health reform was supposed to have been good news for the U.S. Preventive Services Task Force. Until 2009, this independent panel of federally-appointed experts in primary care and preventive health was not particularly well known, and its evaluations of the effectiveness of clinical preventive services had no binding authority on public or private insurance plans. Within the small circle of physicians and policymakers who were aware of the their work, however, the USPSTF won accolades and respect for "calling it as they saw it," sticking strictly to the evidence and writing screening recommendations that frequently conflicted with more expansive guidelines promulgated by other professional organizations.

For example, the USPSTF differed from the Centers for Disease Control and Prevention in finding insufficient evidence to screen for hepatitis C, and only recommending HIV screening in high-risk patients (rather than universal screening between the ages of 13 and 64). Unlike the American Diabetes Association, which endorses testing for diabetes in all patients age 45 or older, the USPSTF found that the evidence supported screening only patients with high blood pressure. The Task Force clashed with the American Academy of Opthalmology in finding insufficient evidence to support routinely screening adults for glaucoma. And it checked the pharmaceutical company-supported enthusiasm for COPD screening by concluding that there was no benefit to routine spirometry in adults without respiratory symptoms.

A more politically-minded group (as federally-supported guideline committees tend to be) would probably have been unable to make such a series of controversial statements without stirring up a public backlash. But here, the USPSTF's low profile served to protect it from the advocacy groups that dominate conversations about federal coverage for health care services. But in 2009, that all changed, as the Task Force was prominently featured in health reform legislation proposed in the U.S. House and the Senate. Ultimately, the Affordable Care Act mandated that USPSTF-endorsed ("A" and "B") preventive services receive first-dollar coverage from Medicare and private health insurance plans.

Scrutiny of the USPSTF quickly intensified, especially after it issued a politically-radioactive new statement that stepped back from recommending routine mammography for women in their 40s. It was tagged as a "death panel" that, in the words of one spectacularly misinformed newspaper columnist, had "gone rogue" and ought to be immediately dissolved. (Not coincidentally, there is a Roger Maris-sized asterisk in the ACA's list of USPSTF "A" and "B" services that basically directs insurers to disregard the USPSTF's 2009 breast cancer recommendations and instead rely on the 2002 version.) With the Task Force literally fighting for its very survival, it was perhaps inevitable that politics would begin trumping science - which goes a long way toward explaining why members were willing to meekly go along with the absurd cover story that their November 2010 meeting was cancelled due to "scheduling conflicts."

In the 17 months since the passage of health reform, the USPSTF has been only a shadow of its independent self. After publishing an average of one new statement per month for most of my tenure on their staff (2006-2010), a public comment process imposed by the Agency for Healthcare Research and Quality turned into a bottleneck for releasing timely, evidence-based recommendations. None of the 4 new statements that have successfully traversed the public comment process has been particularly noteworthy. Osteoporosis: a modest expansion of screening to more high-risk women under the age of 65. Testicular cancer: a reaffirmation of the near-universal consensus that screening is not necessary. Prevention of newborn gonorrhea eye infections: affirming the standard of care. And earlier this week, the USPSTF retreated from its previous recommendation against screening for bladder cancer was not warranted, instead finding insufficient evidence to make a statement one way or the other.

Of course, a Task Force that makes few waves is exactly what the current Administration wants. Never mind that clinicians and patients must continue to wait for long-overdue updates on screening for prostate cancer, screening for oral cancer, breast cancer chemoprevention, and vitamin D and calcium supplements. (All of these topics had already been voted by the Task Force and were within months of publication in March 2010 but have been subsequently delayed, postponed, or suppressed from entering the public comment queue.) How long can this state of affairs reasonably continue? As the 2012 elections draw nearer, how likely is it that the USPSTF will be permitted to advance any science with even remotely political implications? And - though it pains me to ask - is a Task Force that is forced to pull its punches due to politics really that much better than no Task Force at all?

6 comments:

  1. I have used the USPSTF guidelines in my practice for years. This is a great article and very informative. I really appreciate your insight into this issue. Keep it up.

    ReplyDelete
  2. Hi Kenny,
    Linking mammograms and death panels in a post title (and subsequently by others in 140-character tweets) concerns me a lot.

    Breast cancer screening by mammography has nothing to do with "death panels."

    ReplyDelete
  3. Hi Elaine - Thanks for your feedback. I couldn't agree more than mammography (or recommendations that offer women an informed choice whether to have mammograms, rather than require them to do so or feel that they're declining against medical advice) has nothing to do with death panels. The point is that there are a lot of hysterical people (including those with major television / radio / online platforms) who have equated shared decision making in cancer screening as tantamount to "rationing" care, and for those folks, "rationing" is only one step away from mythical death panels. So I apologize if the link bothers you, but I think the horse is already out of the barn - and hopefully Google searchers who link the terms will come across this post rather than others.

    ReplyDelete
  4. Kenny. Thanks for your excellent and timely article. The environment of US medicine has created reactive and defensive practice patterns leading to higher costs. The USPSTF provides physicians evidenced based guidelines (not doctrine)that can help us transform to a patient-centered, prevention-oriented, cost-effective approach. The role of the Task Force is critical if our society hopes to retain access to and confidence in US medicine.

    ReplyDelete
  5. The USPSTF has always been a great guide for primary and community medicine. Mainly because, it explains the reasoning behind the decisions. Decisions that are carefully researched, through resources that many of us are not privy to. For example, our Canadian physician colleagues, have not recommended screening mammograms in premenopausal women, due to the density of breast tissue, and therefore, the higher likelihood of false positive reports.

    So, discussions with patients regarding family history and a careful breast exam, by the physician, is still the most important tools we have for early diagnosis.

    It is very difficult to work when politics and, therefore, fear tactics are factors in delivering high quality care. I even have family members who are extremely anxious of what is in store for them. A reduction in social security and medicare benefits are real concerns.
    Although "death panels" is a term created for political purposes, it should not cause a reaction among professionals, to ignore the real fear, and real cause for concern, that our patients face, every day.

    To be honest, can anyone, really say that rationing of care has never been an option in the U.S.A.

    Anyone practicing in an urban environment, or taking managed care contracts knows that we are all exposed to many forms of rationing of care.

    It takes a great deal of effort to sort through fact from fiction, and then transcribe or translate it into something our patients can rely on.

    Maybe, It is time for us to admit, we too, are also subjected to a lot of unknowns and misguided regulations from many sources, and in fact, we may not be "permitted" to deliver the health care that we are trained to provide and that our patients have learned to expect, here in the U.S.

    ReplyDelete
  6. The USPSTF's work is invaluable for clinical practice. It has a been a great stride for preventive efforts that the ACA has adopted their recommendations as the "de facto" standard.
    It is funny that the organization that the USPSTF was modelled after, the Canadian Taskforce on Preventive Health Care, was disbanded for many years due to "cost constraints". They recently got resurrected to continue their great work.
    This shows that politics drives many decisions in allocation of health care resources and the quintissential proof of politics is the usual public comment/consultation process. Hopefully, their Canadian counterparts will be able to produce results more rapidly in the near future.

    ReplyDelete