USPSTF: Perspectives of a Member Diana Petitti, MD, MPH September 7, 2008 AHRQ “Lunch and Learn”

Evidence-based Medicine [Practice] “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett BMJ 1996; 312: 71-72). “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett BMJ 1996; 312: 71-72).

Evidence-based Medicine [Practice] “the attraction and fundamental soundness of the core idea: that what happens to patients should be based, to the greatest extent possible, on evidence.” (Eddy, Health Affairs, 2005, 24 (1): 9- 17). “the attraction and fundamental soundness of the core idea: that what happens to patients should be based, to the greatest extent possible, on evidence.” (Eddy, Health Affairs, 2005, 24 (1): 9- 17).

Belief without evidence is what is told by one who speaks without knowledge, of things without parallel. Ambrose Bierce Ambrose Bierce

United States Preventive Services Task Force historically led the way in creating evidence-based recommendations for the use (and non-use) of preventive services for the United States United States Preventive Services Task Force historically led the way in creating evidence-based recommendations for the use (and non-use) of preventive services for the United States

USPSTF Independent panel of experts in primary care and prevention; multidisciplinary; volunteers Independent panel of experts in primary care and prevention; multidisciplinary; volunteers –Not being “owned” and/or perceived as “owned” is a major strength

But..... Changes in the status of prevention and in the involvement of specialties other than primary care in prevention have substantially raised the stakes Changes in the status of prevention and in the involvement of specialties other than primary care in prevention have substantially raised the stakes

The “Olden” Days Colorectal cancer screening Colorectal cancer screening –The primary care physician took a stool sample in his/her office and tested it for occult blood using a reagent he/she had in his/her “lab” –OR the primary care physician asked the patient to take home “stool cards” and place a specimen on them and return them to the office to be tested –If positive, they might be repeated with better prep or the patient would be referred to a gastroenterologist for further evaluation (barium enema, colonoscopy, etc.)

OR Colorectal cancer screening Colorectal cancer screening –The primary care physician used a rigid (perish the thought) or flexible sigmoidoscope to visualize the distal colon in order to identify polyps/cancers, which were biopsied by the physician in his/her office and sent to a pathologist. –If cancer was found, the patient would be referred to a surgeon –If polyps were found, they might be removed by the physician; more likely the patient would be referred to a gastroenterologist for a colonoscopy and polyp removal.

The “New Days” Colorectal cancer screening Colorectal cancer screening –Primary care physicians –Radiologists –Gastroenterologists –Geneticists –Companies that make stool blood tests –Companies that make CT equipment –Companies that make tests of mutations in DNA in stool –Companies that make tests of mutations in DNA in blood –Scientists who own patents on the new technologies

The “New Days” Patients, survivors, patients, the media, Wall Street as well as physicians, scientists, companies and the government are stakeholders Patients, survivors, patients, the media, Wall Street as well as physicians, scientists, companies and the government are stakeholders

The “New Days” Prevention has become a “high stakes” field and the members of the Task Force and AHRQ, which provides major support, are “in a fish bowl” Prevention has become a “high stakes” field and the members of the Task Force and AHRQ, which provides major support, are “in a fish bowl”

Misperceptions Compound the Fish Bowl  The TF does not make decisions about coverage (or non-coverage) for any entity Typical systematic review for AHRQ’s EPC program costs $250,000-$500,000

 Insufficient evidence e.g., screening for prostate cancer using PSA age to end screening age to start screening population subgroups The Never-ending and/or Never to End Problem

What Would Make the Job Easier  We need more GOOD evidence Not (just) more clinical trials but (good) clinical trials that address pertinent populations Not more papers (how can we have 6000 journals and 17 million scientific publications per year and not know more?)

What Would Make the Job Easier  Acceptance of other type of evidence when clinical trials will not be informative  Optimal use of observational data  Acceptance of decision-modeling

What Would Make the Job Easier  We need FEWER competing recommendations based on the same evidence  We need to have FEWER groups involved in the recommendation business and to have all of the groups in the business function free of conflicts of interests including both financial and intellectual

What Would Make the Job Easier  We need all stakeholders to “get on the same page” concerning the purpose of medical care in general and prevention in specific To improve health and well-being In general, the purpose of involvement in medical care should not be to get rich For prevention, the purpose is not to save money that would otherwise be expended for other kinds of care

DISCUSSION