Tuesday, September 25, 2012

Prevention potpourri

Several recent publications have highlighted the strengths and limitations of U.S. Preventive Services Task Force recommendations on commonly provided preventive services.

Screening and Interventions for Alcohol Misuse

Yesterday, the USPSTF released a draft recommendation statement on screening and behavioral counseling interventions for alcohol misuse, supported by a comprehensive systematic review published in the Annals of Internal Medicine. (Full disclosure: the lead author of the review is the son of family physician Pat Jonas, who blogs at Dr Synonymous and with whom I've given past presentations on social media.) Although the USPSTF review and statement affirm that brief behavioral counseling has positive effects on risky alcohol use, I believe that the Task Force missed an important opportunity to evaluate the effectiveness of medications such as acamprosate and naltrexone for alcohol-dependent patients in primary care settings. To expect, as the USPSTF appears to do, that alcohol-dependent patients identified by screening will all be referred to addiction specialists seems unreasonable, since the estimated lifetime prevalence of alcohol dependence in the U.S. is 12.5%.

Abdominal Aortic Aneurysm Screening

In 2005, the USPSTF recommended that men age 65 to 75 years who had ever smoked receive a one-time ultrasonography screening for abdominal aortic aneurysm (AAA), a condition that is usually causes no symptoms until the aneurysm ruptures, often leading to death. Previous studies had shown that identifying and repairing large (more than 5.5 centimeters in diameter) aneurysms could avert these deaths. However, a study published last week in the Archives of Internal Medicine found that despite Medicare coverage of AAA screening since 2007, few eligible men had undergone the test and there were no effects on rates of AAA rupture or death. I've always been uncomfortable with this Task Force recommendation because AAA repair surgery carries considerable risk to the patient even in the hands of the most skilled vascular surgeons, and many large AAAs that would not cause problems during men's lifetimes could potentially be overdiagnosed and unnecessarily treated. An accompanying editorial written by my friend and former USPSTF member Russ Harris and colleagues suggests that the population-level benefit of AAA screening may be declining, while the harms may be greater due to the increasing frequency of surgery for smaller AAAs that are even less likely to cause problems. It will be interesting to see if the USPSTF will reconsider its 2005 recommendation.

Counseling for Healthful Diet and Physical Activity

An ambitious project named Prescription for Health funded 22 primary care practice-based research networks between 2003 and 2007 to develop innovative, evidence-based strategies to address tobacco use, risky alcohol use, unhealthy diet, and physical inactivity in their patient populations. An analysis of a subset of 7 PBRNs published in the Journal of the American Board of Family Medicine reflects the mixed results that these interventions achieved and the numerous challenges of providing them in practice. Such considerations could be one reason that the USPSTF declined to endorse routine counseling for healthful diet and physical activity in the general adult population.

Screening for Prostate Cancer

Finally, a research letter in the Archives of Internal Medicine found a modest decline in PSA-based prostate cancer screening in Medicare recipients age 75 years and older (from 29.4% to 27.8%) associated with the USPSTF's 2008 recommendation to discontinue screening in this group. The screening rate remains much too high, especially since the Task Force now recommends against PSA-based screening in men of any age. I will share more of my thoughts about implementing this "don't do" guideline in primary care a future issue of the Journal of Lancaster General Hospital.

2 comments:

  1. Great comments, Kenny (of course, my son is lead author of the alcohol misuse article, but I have no bias). I think you have a good point about the numbers of alcohol dependent and alcohol misusing patients and the need for more intervention strategies. Screening by all family physicians and others in primary care is a good start. Peace. Pat

    ReplyDelete
  2. If you didn't catch the PBS documentary "Money & Medicine" (http://www.pbs.org/programs/money-medicine/) last night, I would highly recommend it the next time it comes around. Reviewing examples of overdiagnosis and overtreatment that drive expensive and unnecessary care in the U.S., such as breast and prostate cancer screening (but also maternity and end-of-life care), it does a great job illustrating why our health system costs so much and achieves so relatively little. As Shannon Brownlee says in the documentary, "Getting rid of care that is bad is not rationing. Getting rid of care that has no benefits is not rationing. It's rational."

    ReplyDelete