Renowned American surgical pioneer William Halsted is probably best known for the cancer operation that bears his name: the Halsted radical mastectomy. First performed in 1882 and the treatment of choice for localized breast cancer until the 1970s, this extremely disfiguring surgery removed the entire affected breast, underlying pectoral (chest wall) muscles, and all of the adjacent lymph nodes. Dr. Halsted and his supporters felt that this operation was superior to removing only the affected breast (or only the affected part of the breast, known as lumpectomy) based on a theory of how breast cancer spread that was ultimately shown to be flawed. When evidence began to emerge in the 1940s that breast cancer recurrence rates following radical mastectomy were no better than those following more conservative surgical techniques, proponents of Halsted's aggressive surgery nonetheless fiercely resisted calls for change for nearly thirty years.
I share this notable episode of medical history to explain the working title of my book-in-progress, Conservative Medicine. In politics, the "conservative" label is usually attached to someone who resists change; in modern medicine, however, conservative physicians are frequently those who are calling for change. For example, the Choosing Wisely campaign sponsored by the American Board of Internal Medicine Foundation discourages physicians from providing, and patients from receiving, common "aggressive" medical tests and treatments that have no clinical benefits and often cause harm. (As general internist and medical educator John Schumann recently observed on his blog, even former U.S. Presidents are not immune to the tendency for physicians to do more than is medically necessary.)
Conservative Medicine will consist of three interweaving and complementary stories. The first is the story of the science of screening tests and other preventive interventions: a tale encompassing a few notable successes but many false hopes and unfulfilled promises. The second story is that of my patients and others whose health was affected by preventive medicine: a few who possibly benefited as well as others who were probably harmed. The third story is my own: the narrative of my gradual evolution as an increasingly skeptical clinician and scientist, including four tumultuous years as a staffer and researcher for the U.S. Preventive Services Task Force, the federally-supported panel that now decides which preventive services health insurers must provide for free.
Only recently have I realized that my personal story will - and must - end up being at the center of my book. Although I have posted many times on Common Sense Family Doctor (and published a longer literary piece) about the adverse effects I experienced from questioning the effectiveness of the prostate-specific antigen (PSA) test for prostate cancer, I wasn't sure who would want to sit through book chapters about the travails of a mid-level government health bureaucrat. On the other hand, working in a federal agency at the center of various political storms provided me with insights that were critical to developing my philosophy as a conservative family physician. The challenge will be using my narrative as a way to advance the larger story of how the good intentions of preventive medicine run amok in our present-day health system. I welcome your suggestions.
**
This is the second in a series of brainstorming posts about a book that I plan to write titled Conservative Medicine.
Tuesday, August 13, 2013
Wednesday, August 7, 2013
Estimating osteoporosis risk in older men
According to a recent review in American Family Physician, 1 to 2 million American men have osteoporosis, 13 percent of white U.S. men older than age 50 will experience an osteoporotic fracture in their lifetimes, and men are twice as likely as women to die in the hospital following a hip fracture. However, unlike screening guidelines in women, there is no consensus on when to screen for osteoporosis in men. The American College of Physicians recommends an individualized osteoporosis risk assessment for men age 65 or older, and dual energy x-ray absorptiometry (DXA) scans to measure bone density in men at increased risk. On the other hand, the U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, although it observed that "men most likely to benefit from screening would have 10-year risks of osteoporotic fracture equal to or greater than those of 65-year-old white women with no additional risk factors."
Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.
In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.
Will the results of this study make physicians more likely to use MORES to assess the risk of osteoporosis in older men? Or will clinicians gravitate toward a universal age-based DXA screening strategy (analogous to screening all women age 65 years or older) to avoid missing any men with osteoporosis?
**
A slightly different version of the above post was first published on the AFP Community Blog.
Since neither organization recommends routinely screening older men for osteoporosis, family physicians require clinical tools to determine which men are at higher risk and therefore candidates for bone density measurement. One such tool, the Male Osteoporosis Risk Estimation Score (MORES), uses age, weight, and the presence or absence of chronic obstructive pulmonary disease to calculate a risk score and recommends further evaluation in men at a certain point threshold. However, since MORES was derived and validated in an historic national survey sample, until recently its utility in a present-day primary care setting was unknown.
In the July/August issue of the Journal of the American Board of Family Medicine, Drs. Alvah Cass and Angela Shepherd evaluated the performance of MORES in a cross-sectional sample of 346 men age 60 years or older presenting to family medicine, internal medicine, or geriatric outpatient practices at the University of Texas, Galveston. MORES correctly identified 12 of the 15 men in the study with osteoporosis of the hip, yielding a sensitivity of 80% and a specificity of 70%. Based on these results, 259 men would need to be screened with MORES to prevent one major osteoporotic fracture over 10 years, compared to 636 with a universal DXA strategy.
Will the results of this study make physicians more likely to use MORES to assess the risk of osteoporosis in older men? Or will clinicians gravitate toward a universal age-based DXA screening strategy (analogous to screening all women age 65 years or older) to avoid missing any men with osteoporosis?
**
A slightly different version of the above post was first published on the AFP Community Blog.
Monday, July 29, 2013
Should you be screened for lung cancer? Maybe not, and here's why
If you are a lifelong heavy smoker age 55 years or older, the U.S. Preventive Services Task Force believes that screening for lung cancer with CT scans may save your life. Today the Task Force released provisional recommendations that assigned a "B" letter grade to this preventive service, which, if eventually finalized, would place CT scans alongside established cancer screening tests such as mammograms and Pap smears and mandate that health insurers cover these scans without cost sharing for eligible patients.
The scientific basis of the USPSTF's new recommendations is a large U.S. study sponsored by the National Cancer Institute that concluded in 2011 that heavy smokers randomly assigned to screening with CT scans had a 20 percent lower relative risk of death than heavy smokers randomly assigned to screening with chest x-rays. However, a more recent analysis by the same researchers found that the absolute benefit of CT screening in this study varied greatly according to a patient's baseline risk of lung cancer death. For the highest-risk patients, the chance of CT scans preventing death from lung cancer is about 1 in 100 (a 5% risk of lung cancer death over 6 years without screening minus a 4% risk with screening); for lower-risk patients, that chance is about 1 in 5000 (a 0.1% risk of lung cancer death without screening minus a 0.08% risk of death with screening).
For patients in the lower-risk group, for whom the potential lifesaving benefits of CT scans are very small, the downsides of the screening test become considerably more important. Screening tests have harms just like any other medical procedure, and it's important for your doctor to thoroughly review those harms with you if you are considering screening. In my mind, there are at least 4 good reasons for current or former smokers to think twice about being screened for lung cancer:
1. The risk of developing cancer from the CT scan itself isn't trivial. An analysis published in the Archives of Internal Medicine found that a typical chest CT scan exposes patients to the radiation equivalent of more than 100 chest X-rays, and that at age 60, an estimated 1 in 1000 women or 1 in 2000 men would eventually develop cancer from that single scan. Although some imaging centers now use lower radiation doses, repeating these lower-dose CT scans annually still adds up. (It hasn't been long enough since the conclusion of the NCI's lung cancer screening study to measure how much these scans increased the participants' risk for other cancers.)
2. False alarms are extremely common. In the NCI's study, more than 96 percent of all positive results turned out to be false positives, and in a previous CT screening study, 1 in 3 patients had at least one false-positive result after undergoing only two CT scans. Of those patients, 1 in 14 needed an invasive lung biopsy to be sure they were cancer-free. Such diagnostic procedures for lung cancer can themselves be life-threatening: in 2005, former Canadian prime minister Brian Mulroney (a longtime heavy smoker) spent several weeks in the intensive care unit after postoperative complications from surgery to remove two lung nodules found on a screening CT scan that turned out to be non-cancerous.
3. A CT scan for lung cancer could find some other unrelated abnormality that will require further investigation; in the NCI's study, this occurred in about 1 in every 13 patients. You might think this is a good thing, but most of these abnormalities (known as "incidentalomas") turn out to be false alarms, too. In fact, in 2008 this very same Task Force decided against endorsing CT screening for colorectal cancer due to concerns that invasive testing to definitively diagnose all of the abnormalities that CT scans turn up could easily outweigh the cancer-prevention benefits.
4. Finally, even if screening catches a true lung cancer early, there's no guarantee your prognosis will be better. This is due to "overdiagnosis," or the unnecessary diagnosis of a condition (typically cancer) that will never cause symptoms in a patient's lifetime, either because it's so slow-growing or the patient dies from some other cause. (Statistics show that most lifelong smokers will die from heart disease, not lung cancer.) An estimated 1 in 3 breast cancers detected by screening mammograms is overdiagnosed, and a 2007 study published in the journal Radiology suggested that the proportion of lung cancers overdiagnosed by CT scans could be as high or higher, especially in women. But because there's no way of knowing at the time of diagnosis if a lung cancer will be fatal, inevitably most of these patients will be needlessly subjected to the side effects of treatment - making the "cure" worse than the disease.
I expect that some of my patients will decide to be screened with CT scans for the obvious upside emphasized by the U.S. Preventive Services Task Force: a small chance of preventing death from lung cancer. But before they make this decision, I will counsel them to carefully consider the more likely downsides, and only choose testing if they're prepared for these too.
**
This post's title is modeled after the title of the excellent book Should I Be Tested for Cancer? Maybe Not and Here's Why by H. Gilbert Welch, MD, MPH. Portions of this post are revised and updated from a previous post on Common Sense Family Doctor.
The scientific basis of the USPSTF's new recommendations is a large U.S. study sponsored by the National Cancer Institute that concluded in 2011 that heavy smokers randomly assigned to screening with CT scans had a 20 percent lower relative risk of death than heavy smokers randomly assigned to screening with chest x-rays. However, a more recent analysis by the same researchers found that the absolute benefit of CT screening in this study varied greatly according to a patient's baseline risk of lung cancer death. For the highest-risk patients, the chance of CT scans preventing death from lung cancer is about 1 in 100 (a 5% risk of lung cancer death over 6 years without screening minus a 4% risk with screening); for lower-risk patients, that chance is about 1 in 5000 (a 0.1% risk of lung cancer death without screening minus a 0.08% risk of death with screening).
For patients in the lower-risk group, for whom the potential lifesaving benefits of CT scans are very small, the downsides of the screening test become considerably more important. Screening tests have harms just like any other medical procedure, and it's important for your doctor to thoroughly review those harms with you if you are considering screening. In my mind, there are at least 4 good reasons for current or former smokers to think twice about being screened for lung cancer:
1. The risk of developing cancer from the CT scan itself isn't trivial. An analysis published in the Archives of Internal Medicine found that a typical chest CT scan exposes patients to the radiation equivalent of more than 100 chest X-rays, and that at age 60, an estimated 1 in 1000 women or 1 in 2000 men would eventually develop cancer from that single scan. Although some imaging centers now use lower radiation doses, repeating these lower-dose CT scans annually still adds up. (It hasn't been long enough since the conclusion of the NCI's lung cancer screening study to measure how much these scans increased the participants' risk for other cancers.)
2. False alarms are extremely common. In the NCI's study, more than 96 percent of all positive results turned out to be false positives, and in a previous CT screening study, 1 in 3 patients had at least one false-positive result after undergoing only two CT scans. Of those patients, 1 in 14 needed an invasive lung biopsy to be sure they were cancer-free. Such diagnostic procedures for lung cancer can themselves be life-threatening: in 2005, former Canadian prime minister Brian Mulroney (a longtime heavy smoker) spent several weeks in the intensive care unit after postoperative complications from surgery to remove two lung nodules found on a screening CT scan that turned out to be non-cancerous.
3. A CT scan for lung cancer could find some other unrelated abnormality that will require further investigation; in the NCI's study, this occurred in about 1 in every 13 patients. You might think this is a good thing, but most of these abnormalities (known as "incidentalomas") turn out to be false alarms, too. In fact, in 2008 this very same Task Force decided against endorsing CT screening for colorectal cancer due to concerns that invasive testing to definitively diagnose all of the abnormalities that CT scans turn up could easily outweigh the cancer-prevention benefits.
4. Finally, even if screening catches a true lung cancer early, there's no guarantee your prognosis will be better. This is due to "overdiagnosis," or the unnecessary diagnosis of a condition (typically cancer) that will never cause symptoms in a patient's lifetime, either because it's so slow-growing or the patient dies from some other cause. (Statistics show that most lifelong smokers will die from heart disease, not lung cancer.) An estimated 1 in 3 breast cancers detected by screening mammograms is overdiagnosed, and a 2007 study published in the journal Radiology suggested that the proportion of lung cancers overdiagnosed by CT scans could be as high or higher, especially in women. But because there's no way of knowing at the time of diagnosis if a lung cancer will be fatal, inevitably most of these patients will be needlessly subjected to the side effects of treatment - making the "cure" worse than the disease.
I expect that some of my patients will decide to be screened with CT scans for the obvious upside emphasized by the U.S. Preventive Services Task Force: a small chance of preventing death from lung cancer. But before they make this decision, I will counsel them to carefully consider the more likely downsides, and only choose testing if they're prepared for these too.
**
This post's title is modeled after the title of the excellent book Should I Be Tested for Cancer? Maybe Not and Here's Why by H. Gilbert Welch, MD, MPH. Portions of this post are revised and updated from a previous post on Common Sense Family Doctor.
Friday, July 19, 2013
Conservative Medicine: the big idea (and title) of my book
A few days ago I was reminiscing about my family medicine residency, where at one of my outpatient training sites I provided care to Amish patients in rural southern Lancaster County, Pennsylvania. The Amish didn't believe in checkups and rarely visited doctors, so we knew that when they did come in, there was usually a serious problem. Abdominal pain was more likely to be from perforated appendicitis than indigestion; leg pain was more likely to be from a life-threatening traumatic injury than a sprained ankle; and so on. There was nothing routine about providing health care for this population, and I found the experience refreshing.
On the other hand, my residency training also made me a big believer in preventive medicine, which is why I subsequently spent several years working with the U.S. Preventive Services Task Force, searching the literature for evidence to distinguish effective screening tests (such as screening for osteoporosis in older women) from ineffective and potentially harmful ones (such as screening for prostate cancer in older men). Unfortunately, as in other areas of health care, preventive medicine has been corrupted by big business, fear of lawsuits, and the widely held (and generally wrong) notion that more care is better care. As a result, unscrupulous companies such as Life Line Screening take advantage of vulnerable elders by selling packages of unnecessary tests at health fairs and churches; obstetricians continue to perform annual pelvic examinations even though these exams have no value in nonpregnant women without symptoms; and gastroenterologists tell patients with normal screening colonoscopies to return for repeat screenings much sooner than the appropriate interval of 10 years.
Looking back on my nearly 4 years of blogging, an overarching theme has been finding the "sweet spot" between too little care ("Amish medicine") and excessive medical interventions ("Life Line medicine"). This sweet spot is the starting point for a book that I'm planning to write with the working title of Conservative Medicine. It would have been easy to borrow the title of this blog and just call it "Common Sense Family Doctor," but the reality is that a lot of truths about preventive care and screening aren't common sense, and family doctors are not the only health professionals with expertise on these subjects.
The big idea of Conservative Medicine is that much of what passes for preventive health care in this country (and will be paid for by the implementation of the Affordable Care Act, aka Obamacare) is useless, unhelpful, and likely to make patients less, not more, healthy. There is no such thing as a harmless test; seemingly "routine" tests may do more harm than good; and even the well-established preventive health physical has little evidence of benefit.
My next several posts will flesh out Conservative Medicine by addressing the 5 questions that I'm told every prospective author needs to answer in a serious nonfiction book proposal:
1. What's the book about?
2. What's new about the book?
3. Why are you the best person to write it?
4. Why is now the right time for it?
5. Who needs to read it?
This book proposal is a work in progress, and this set of posts will in some ways be a departure from the usual fare of Common Sense Family Doctor. For one thing, I hope to receive many constructive comments about how to best shape my book and distinguish it from similar books (for example, Shannon Brownlee's Overtreated, H. Gilbert Welch's Overdiagnosed, and Otis Brawley's How We Do Harm). I want my book to be about a lot more than prostate cancer politics, but welcome suggestions about how to incorporate my compelling personal narrative into the larger story of a health system that has largely lost sight of what health really means. To my longtime and occasional readers, thanks in advance for your words of wisdom.
On the other hand, my residency training also made me a big believer in preventive medicine, which is why I subsequently spent several years working with the U.S. Preventive Services Task Force, searching the literature for evidence to distinguish effective screening tests (such as screening for osteoporosis in older women) from ineffective and potentially harmful ones (such as screening for prostate cancer in older men). Unfortunately, as in other areas of health care, preventive medicine has been corrupted by big business, fear of lawsuits, and the widely held (and generally wrong) notion that more care is better care. As a result, unscrupulous companies such as Life Line Screening take advantage of vulnerable elders by selling packages of unnecessary tests at health fairs and churches; obstetricians continue to perform annual pelvic examinations even though these exams have no value in nonpregnant women without symptoms; and gastroenterologists tell patients with normal screening colonoscopies to return for repeat screenings much sooner than the appropriate interval of 10 years.
Looking back on my nearly 4 years of blogging, an overarching theme has been finding the "sweet spot" between too little care ("Amish medicine") and excessive medical interventions ("Life Line medicine"). This sweet spot is the starting point for a book that I'm planning to write with the working title of Conservative Medicine. It would have been easy to borrow the title of this blog and just call it "Common Sense Family Doctor," but the reality is that a lot of truths about preventive care and screening aren't common sense, and family doctors are not the only health professionals with expertise on these subjects.
The big idea of Conservative Medicine is that much of what passes for preventive health care in this country (and will be paid for by the implementation of the Affordable Care Act, aka Obamacare) is useless, unhelpful, and likely to make patients less, not more, healthy. There is no such thing as a harmless test; seemingly "routine" tests may do more harm than good; and even the well-established preventive health physical has little evidence of benefit.
My next several posts will flesh out Conservative Medicine by addressing the 5 questions that I'm told every prospective author needs to answer in a serious nonfiction book proposal:
1. What's the book about?
2. What's new about the book?
3. Why are you the best person to write it?
4. Why is now the right time for it?
5. Who needs to read it?
This book proposal is a work in progress, and this set of posts will in some ways be a departure from the usual fare of Common Sense Family Doctor. For one thing, I hope to receive many constructive comments about how to best shape my book and distinguish it from similar books (for example, Shannon Brownlee's Overtreated, H. Gilbert Welch's Overdiagnosed, and Otis Brawley's How We Do Harm). I want my book to be about a lot more than prostate cancer politics, but welcome suggestions about how to incorporate my compelling personal narrative into the larger story of a health system that has largely lost sight of what health really means. To my longtime and occasional readers, thanks in advance for your words of wisdom.
Saturday, July 13, 2013
Screening-illiterate physicians may do more harm than good
On the first day of the clinical preventive medicine course that I teach every spring, I review the concept of lead-time bias and its potential to make a screening test look more effective than it really is (or, effective when it's not). In a previous blog post, I explained how lead-time bias deceptively improves 5-year survival statistics. The basic idea is that by advancing the time in the disease course that cancer (or some other condition) is detected, screening will always increase the percentage of patients who survive for 5 years or more, even if it doesn't do anything to reduce mortality. This concept is as basic to the appropriate use of screening tests as vital signs are to the practice of medicine. In my opinion, any physicians who don't understand lead-time bias ought to have their test-ordering privileges suspended until they do.
Unfortunately, a study published last year in the Annals of Internal Medicine concluded that a whole lot of clinicians require remedial education regarding lead-time bias. A national sample of more than 400 primary care physicians were provided scenarios about the effects of two hypothetical screening tests. The first test improved 5-year survival from 68 to 99 percent, and the second reduced the mortality rate from 2 deaths per 1000 to 1.6 deaths per 1000. 95 percent of surveyed physicians said that they would "definitely" or "probably" recommend the test that improved 5-year survival, even though this information (which is based on lead-time statistics associated with screening for prostate cancer) provides absolutely no evidence that the test improves patient outcomes. In contrast, considerably fewer physicians were enthusiastic about the test that actually lowered the mortality rate, perhaps because the absolute risk reduction seemed unimpressive by comparison.
Another disappointing finding was that almost half of surveyed physicians believed that a screening test "saves lives" if more cancers are detected in screened than in unscreened populations. The truth is, finding more cancers is a poor assurance of better outcomes. For example, a randomized trial of screening for ovarian cancer found no difference in mortality rates between women assigned to annual screening versus those receiving usual care despite 21% more cancers being detected in the screening group. This study confirmed what most medical organizations had suspected for years in recommending against ovarian cancer screening in asymptomatic women. Unfortunately, another survey found that one-third of a nationally representative sample of family physicians, general internists, and obstetricians nonetheless believe that ovarian cancer screening is effective. (Similar levels of ignorance exist among subspecialists, which may explain why so many urologists continue to believe that PSA screening saves lives.)
The Institute of Medicine has identified low levels of health literacy in the general population as a major obstacle to ensuring optimal health and quality of care. But how can physicians expect our patients to make informed decisions regarding screening tests when large numbers of us are functionally illiterate regarding basic screening concepts? As a medical educator, I took home this message from these studies: medical schools, residency programs, and certifying boards must devote more time and effort to improving physicians' literacy regarding screening, lest misleading survival statistics continue to fuel overuse of ineffective tests and expose countless patients to potential harm.
**
A slightly different version of the above post first appeared on Common Sense Family Doctor on March 5, 2012.
Unfortunately, a study published last year in the Annals of Internal Medicine concluded that a whole lot of clinicians require remedial education regarding lead-time bias. A national sample of more than 400 primary care physicians were provided scenarios about the effects of two hypothetical screening tests. The first test improved 5-year survival from 68 to 99 percent, and the second reduced the mortality rate from 2 deaths per 1000 to 1.6 deaths per 1000. 95 percent of surveyed physicians said that they would "definitely" or "probably" recommend the test that improved 5-year survival, even though this information (which is based on lead-time statistics associated with screening for prostate cancer) provides absolutely no evidence that the test improves patient outcomes. In contrast, considerably fewer physicians were enthusiastic about the test that actually lowered the mortality rate, perhaps because the absolute risk reduction seemed unimpressive by comparison.
Another disappointing finding was that almost half of surveyed physicians believed that a screening test "saves lives" if more cancers are detected in screened than in unscreened populations. The truth is, finding more cancers is a poor assurance of better outcomes. For example, a randomized trial of screening for ovarian cancer found no difference in mortality rates between women assigned to annual screening versus those receiving usual care despite 21% more cancers being detected in the screening group. This study confirmed what most medical organizations had suspected for years in recommending against ovarian cancer screening in asymptomatic women. Unfortunately, another survey found that one-third of a nationally representative sample of family physicians, general internists, and obstetricians nonetheless believe that ovarian cancer screening is effective. (Similar levels of ignorance exist among subspecialists, which may explain why so many urologists continue to believe that PSA screening saves lives.)
The Institute of Medicine has identified low levels of health literacy in the general population as a major obstacle to ensuring optimal health and quality of care. But how can physicians expect our patients to make informed decisions regarding screening tests when large numbers of us are functionally illiterate regarding basic screening concepts? As a medical educator, I took home this message from these studies: medical schools, residency programs, and certifying boards must devote more time and effort to improving physicians' literacy regarding screening, lest misleading survival statistics continue to fuel overuse of ineffective tests and expose countless patients to potential harm.
**
A slightly different version of the above post first appeared on Common Sense Family Doctor on March 5, 2012.
Wednesday, July 10, 2013
Uncertain benefits of medicating mild hypertension
In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood pressure of 90 to 99 mm Hg) on cardiovascular outcomes or mortality. However, the randomized trials' relatively small number of participants (fewer than 9000) and short follow-up periods (five years or less) left open the possibility that a significant benefit could still exist. Therefore, Dr. Guirguis-Blake concluded: "Larger double-blinded RCTs in this population of patients with stage 1 hypertension are needed to clarify the potential long-term benefits of pharmacologic therapy."
When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.
With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.
**
The above post was first published on the AFP Community Blog.
When existing research does not adequately answer an important clinical question - in this case, are medications superior to lifestyle modifications or no treatment for mild hypertension? - researchers invariably recommend collecting more evidence. But is performing a large randomized trial of mild hypertension management feasible, given that the standard of care set in 2003 by the Seventh Report of the Joint National Committee (JNC-7) (and reflected in this AFP Point-of-Care Guide) is to routinely identify and treat blood pressures in this range? The U.S. Preventive Services Task Force apparently thinks so; after previously declaring that the benefits of screening were "well established," the USPSTF has released an extensive draft research plan to reevaluate benefits, harms, best methods, and recommended intervals for screening for high blood pressure in adults.
With the next USPSTF statement at least a few years down the road, current evidence-based guidance on hypertension management is limited. The U.S. National Heart, Lung, and Blood Institute, which convened the previous JNC panels, recently announced in a cardiology journal its intention to stop producing guidelines. Instead, it says it will partner with outside medical groups to release its long-delayed JNC-8 hypertension guideline. Since guidelines sponsored by subspecialty societies are less likely to adhere to Institute of Medicine standards for producing unbiased guidelines, family physicians and other primary care clinicians should advocate for their organizations to participate in this process.
**
The above post was first published on the AFP Community Blog.
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