Friday, January 21, 2011

"Politics trumped science": screening for osteoporosis

According to the U.S. Preventive Services Task Force's new recommendation statement on screening for osteoporosis, published earlier this week, "By 2012, approximately 12 million Americans older than 50 years are expected to have osteoporosis. One half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime; 25% of these women will develop a vertebral deformity, and 15% will experience a hip fracture." In other words, the national health burden of this disease is enormous.

The science of the new statement is solid. In 2002, the USPSTF recommended screening for osteoporosis in all women age 65 and older, and in women age 60-64 with "risk factors," but declined to specify which precise risk factors to use, and said nothing about screening in younger women or men. The new guideline advises using the FRAX risk assessment tool to determine if a younger woman has a fracture risk level that would make her likely to benefit from screening, and cautions that there isn't yet enough evidence to recommend screening in men. So far, so good. So what's the problem, and where in the process did politics get involved?

The problem, in my view, is that all of these facts were known more than two years ago, in November 2008, when a previous incarnation of the USPSTF (of which about half of the members remain on the panel) actually voted for these new recommendations. At that time, a typical interval between a Task Force vote to recommendation release was 9 to 12 months, and even that length of time was considered by many USPSTF members to be unacceptable, given the critical public health implications of many of these statements. (In a congressional hearing held in December 2009, USPSTF Chair Ned Calonge acknowledged that the 16-month interval between the vote and publication of the breast cancer screening recommendations was "much too long.")

After the mammography debacle, though, the output of the USPSTF ground to a halt. After releasing an average of one new or updated recommendation each month for the previous 3 years, the Task Force published no new recommendations for nearly a year. All in-progress statements, including several (such as screening for osteoporosis) that were in press as of December 2009, were ordered to be withdrawn by a White House and DHHS leadership that would tolerate no further potential threats to the passage of health reform legislation. And even after the Affordable Care Act became law in March 2010, no remotely controversial statements were permitted to be introduced into the USPSTF's new public comment process until after the November 2010 midterm elections. Statements that were shelved for a year or more (and remain unreleased, even in draft form) include clinically significant, but politically sensitive topics such as breast cancer chemoprevention (voted in March 2009), screening for oral cancer (voted in March 2009), and vitamin D supplementation (voted in November 2009).

If you've read this blog before, you know that I support health reform, even though I don't agree with many specific components of the legislation. And I understand the argument that not presenting health reform opponents with a convenient target might be a reasonable short-term, or even long-term, political strategy. But to a family physician, "health reform" is more than a nice idea, a weighty piece of legislation, or a partisan political achievement. It's about doing what's best for our patients. And if we achieve "health reform" that grants insurance cards to 32 million more people, but doesn't provide them with reliable access to primary care; selectively muzzles experts whom primary care physicians trust to tell them what works and what doesn't in clinical prevention; and willfully allows outdated recommendations to guide coverage of primary care screening to prevent many of 1.5 million life-altering osteoporotic fractures that occur in the U.S. each year, then, well, we have achieved very little at all.


  1. I think this is an excellent post. I think that the general public doesn't understand where these recommendations come from or why. These are public health recommendations and they by definition have to do a cost benefit analysis. That will be part of the health care reform and the kinds of problems and controversy will continue. The real problem is that these recommendations are used as a template for what plans will pay for. When a recommendation like that mammogram mess come out it can lead to plans not paying for important screening even when it might be clinically indicated. So I agree, that politics and science will often clash, leaving recommendations lagging behind. Great post.

  2. This doesn't take away from your point, but it's worth noting that the draft of the osteoporosis guidelines was published in July. I wrote about them then:

    As I noted in that story:

    The release of these draft guidelines mark a change in how the USPSTF will put forth its recommendations, Calonge told Reuters Health. In the past, they simply released final versions of their recommendations, but they have been quietly working on ways to release drafts for public comment, before the guidelines were final.

    For one month, the draft will be available for comment on the group's website here. Based on the feedback, the group may change its recommendations.

    "We've decided that since the miscommunication and the reaction to the breast cancer screening guidelines, that we wanted to accelerate the process," Calonge said, referring to mammography recommendations released last November that were met with controversy.

    The 2002 osteoporosis screening recommendations remain in force until the new ones are finalized, Calonge said. "We're not recommending clinicians use this recommendation until final release."

    Ivan Oransky, MD
    Executive Editor, Reuters Health

  3. Thanks for the note, Ivan. You are quite correct that the draft osteoporosis recommendation was posted online for public comment for 4 weeks in July 2010. I'm actually in favor of the new process and hope that it ultimately leads to greater transparency in recommendation-making and public acceptance of USPSTF statements. Unfortunately, last year it was basically used to obfuscate the fact that certain potentially more controversial statements were deliberately delayed for publication for purely political (rather than scientific) reasons. Also, Task Force members were not informed about which statements were being held up, and why. (A former member told me that they were "kept in the dark" about why some statements made it to press much more slowly than others.)

  4. Guidelines committees should “speak” to the lay public and encourage people to think about what they would do after a screening test shows you have osteoporosis. It’s likely that I have this condition and have good chance of having a hip fracture around age 80. But I have chosen never to have a bone density test because I have made an informed decision not to take a bisphosphonate. Reasons: the magnitude of the benefit is extremely small and the magnitude of the risks remains largely unknown due to our poor post-marketing surveillance system. I’ve yet to see a guidelines committee deal honestly with the decision that comes after a screening test detects a problem.