Tuesday, May 31, 2011

PPIP: Prevention Politics Injures Patients

PPIP is an acronym that officially stands for "Put Prevention Into Practice," which serves as both the name of the Agency for Healthcare Research and Quality's programs to disseminate the preventive care recommendations of the U.S. Preventive Services Task Force as well as the tagline for a series of case study questions about these recommendations that I wrote for the journal American Family Physician from 2008 to 2010. Given the unfortunate events that have occurred since the USPSTF became inextricably linked to the Obama health care reform bill, however, I now propose a new meaning for PPIP: Prevention Politics Injures Patients.

In a recent New York Times editorial, "Squandering Medicare's Money," Archives of Internal Medicine editor Rita Redberg, MD pointed out that the Medicare program paid physicians more than $40 million in 2009 for screening colonoscopies in patients over age 75, and $50 million in 2008 for PSA screening in men age 75 and older and Pap smears in women age 65 and older. That's nearly $100 million alone for 3 tests that the USPSTF concluded have few or zero health benefits and have a high potential to cause harm, and it doesn't count the additional millions (billions?) of dollars of additional testing and procedures that result from these unnecessary screenings. Dr. Redberg writes:

Our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test. So while Medicare is obligated to follow the [U.S. Preventive Services] task force’s recommendations to cover new preventive services, it has no similar mandate to deny coverage for services for which the task force has found no benefit.

Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.

Unfortunately, Dr. Redberg is only seeing the tip of the iceberg. Since health reform became law in March 2010, the Task Force has been keeping an unusually low profile. They cancelled their November 2010 meeting (or rather, as I've previously argued, this meeting was a victim of midterm election politics), and when widely respected pediatrician Virginia Moyer was appointed the group's new Chair in March, the only press release came from her academic institution, rather than AHRQ. Even though it's more critical than ever to get the best evidence on preventive care into the hands of primary care clinicians and patients, the USPSTF has only released 6 draft recommendation statements for public comment in the past 14 months, and of those, only two (screening for osteoporosis and screening for testicular cancer) have been published. As a result, its guidelines are aging rapidly; well over half of the group's active recommendations are more than 5 years old and no longer considered up-to-date by the National Guideline Clearinghouse.

Among these outdated recommendations is one on screening for oral cancer, which the USPSTF released in February 2004 and would have likely updated more than a year ago had prevention politics not intervened. In March 2009, I presented a summary of new evidence on oral cancer screening to the USPSTF, which then voted to update its previous recommendation. The new recommendation statement and evidence summary were accepted for publication by the Annals of Internal Medicine that November - in the same week that the Task Force's new position on screening mammography led to a public uproar.

It soon became apparent that any cancer screening statement that was anything less than an unqualified endorsement would not be politically acceptable to the Administration. Not only were we told to withdraw the new recommendation from Annals' publication queue, it wasn't even allowed to be released for public comments until well after the 2010 midterm elections, at which point the evidence was more than 2 years old and I had decided to resign from AHRQ. I've since offered to work for free on updating the evidence manuscript, but have been told that a (political) decision has been made to start from scratch instead, with a new, independently authored evidence update that will presumably require a new USPSTF vote. I'd now be very surprised if the 2004 recommendation is updated before 2013.

These kinds of delays are not just academic; they have real health consequences. If there is strong evidence that screening for oral cancer in primary care settings has no benefits, primary care clinicians need to know that so they can spend their limited time and resources on services more likely to help patients. If there is strong evidence that the PSA test should be abandoned for prostate cancer screening, we need to know that too. Although I've previously stated my belief that prevention politics will hurt the USPSTF's credibility in the long run, the bottom line is that physicians' lack of access to timely, evidence-based information about what works (and doesn't work) in preventive care injures patients, too.