Monday, May 22, 2017

Colorectal cancer and falls: too much and too little prevention

One of the paradoxes of the U.S. health care system is that excess and waste often exist side by side with insufficiently provided services. Colorectal cancer screening is a prime example. Previous studies showed that 25% of Medicare recipients undergo repeat screening colonoscopies sooner than necessary, but the Centers of Disease Control and Prevention recently reported that nearly 4 in 10 adults between ages 50 and 75 are not up-to-date on colorectal cancer screening. Last year, I argued that the U.S. Preventive Services Task Force's decision to expand the number of recommended screening options based on inadequate evidence was unlikely to improve this situation.

In an editorial in the May 15th issue of American Family Physician, I and Dr. Jennifer Frost explained why the American Academy of Family Physicians disagreed with the new recommendations, and instead chose not to recommend CT colonography or fecal DNA testing and to also reaffirm its previous stance against screening adults older than 85 years. BMJ journalist Jeanne Lenzer's question about whether the USPSTF remains a voice of caution remains relevant in an era of increasingly elastic evidence letter grades (see "C" for prostate cancer screening).

Another area where there may be too much prevention occurring for too little benefit is screening and treatment for osteoporosis, which Ray Moynihan and colleagues reported that in contrast to the medical literature, community-dwelling older women would prefer to describe as a "risk factor" rather than a "disease." I couldn't agree more; we physicians focus too much on prescribing drugs to treat low bone density and too little on interventions to address the other critical risk factor for hip fractures: falling.

So I hope that many patients will read and heed Paula Span's recent New York Times column advising older adults to invest in home modifications that will allow them to move safely around their living spaces as they age. Unfortunately, there aren't nearly enough Certified Aging in Place Specialist (CAPS) contractors to meet national needs. Also, many health insurers that would have no issues paying for a PSA test or screening colonoscopy in a 90 year-old would balk at reimbursing home renovations, even though the latter is much more likely to prevent (rather than cause) a hospitalization.

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