Using the Medical Using the Medical Literature to Make Literature to Make

Decisions About Decisions About Preventive Health Preventive Health

ServicesServicesKenny Lin, MDKenny Lin, MD

Associate Editor, Associate Editor, Essential Essential Evidence PlusEvidence Plus

Associate Editor, Associate Editor, American Family American Family PhysicianPhysician

May 17, 2011May 17, 2011

DisclosuresDisclosures Associate Editor, Associate Editor, Essential Evidence PlusEssential Evidence Plus

(Wiley)(Wiley) Associate Editor, Associate Editor, American Family American Family

Physician Physician (AAFP)(AAFP) Adjunct Faculty PositionsAdjunct Faculty Positions

Georgetown University School of MedicineGeorgetown University School of Medicine Johns Hopkins Univ. School of Public HealthJohns Hopkins Univ. School of Public Health Uniformed Services Univ. of the Health Uniformed Services Univ. of the Health

SciencesSciences Former Medical Officer, Agency for Former Medical Officer, Agency for

Healthcare Research and Quality (DHHS)Healthcare Research and Quality (DHHS)

Learning ObjectivesLearning Objectives

Review the burden of chronic preventable Review the burden of chronic preventable diseases in the United States.diseases in the United States.

Estimate the potential for improving health Estimate the potential for improving health through effective clinical prevention.through effective clinical prevention.

Understand the importance of using an Understand the importance of using an evidence-based process to develop evidence-based process to develop preventive health guidelines based on preventive health guidelines based on searches of the medical literature.searches of the medical literature.

Introduce multiple tools for accessing Introduce multiple tools for accessing preventive health information at the point preventive health information at the point of care.of care.

““An ounce of prevention is An ounce of prevention is worth a pound of cure”worth a pound of cure”

Burden of Chronic Burden of Chronic Illness in the United Illness in the United

StatesStates

Causes of Death - Causes of Death - Diagnoses, 2000Diagnoses, 2000

CauseCause No of deathsNo of deaths death rate*death rate*

Heart disease Heart disease 710 760 710 760 258.2258.2

CancerCancer 553 091 553 091 200.9200.9 Cerebrovascular disease Cerebrovascular disease 167 661 167 661 60.960.9 COPD COPD 122 009 122 009 44.344.3 Unintentional injuries Unintentional injuries 97 900 97 900

35.635.6 Diabetes mellitus Diabetes mellitus 69 301 69 301 25.225.2 Influenza and pneumonia Influenza and pneumonia 65 313 65 313 23.723.7 Alzheimer disease Alzheimer disease 49 558 49 558 1818 Nephritis/nephrosis Nephritis/nephrosis 37 251 37 251 13.513.5 Septicemia Septicemia 31 224 31 224 11.311.3 Other Other 499 283 499 283 181.4181.4 Total Total 2 403 351 2 403 351 873.1873.1

* Per 100,000* Per 100,000

Ref: Mokdad AH, Marks JS, Stroup DF, Gergerding JL. Ref: Mokdad AH, Marks JS, Stroup DF, Gergerding JL. JAMA. 2004;291:1238-1245JAMA. 2004;291:1238-1245

Actual Causes of Death - Actual Causes of Death - 20002000

Actual Cause Actual Cause No. (%) in 1990No. (%) in 1990* * No. (%) No. (%) in 2000in 2000

Tobacco Tobacco 400 000 (19) 400 000 (19) 435 000 (18.1)435 000 (18.1)Diet/phys. inactivity Diet/phys. inactivity 300 000 (14) 300 000 (14) 365 000 365 000

(15.2)(15.2)ETOH ETOH 100 000 (5) 100 000 (5) 85 000 (3.5)85 000 (3.5)Microbial agents Microbial agents 90 000 (4) 90 000 (4) 75 000 (3.1)75 000 (3.1)Toxic agents Toxic agents 60 000 (3) 60 000 (3) 55 000 (2.3)55 000 (2.3)Motor vehicle Motor vehicle 25 000 (1) 25 000 (1) 43 000 (1.8)43 000 (1.8)Firearms Firearms 35 000 (2) 35 000 (2) 29 000 (1.2)29 000 (1.2)Sexual behavior Sexual behavior 30 000 (1) 30 000 (1) 20 000 (0.8)20 000 (0.8)Illicit drug use Illicit drug use 20 000 (1) 20 000 (1) 17 000 (0.7)17 000 (0.7)Total Total 1 060 000 1 060 000 (50) (50) 1 124 000 1 124 000

(46.7)(46.7)

Ref: Mokdad AH, Marks JS, Stroup DF, Gergerding JL. Ref: Mokdad AH, Marks JS, Stroup DF, Gergerding JL. JAMA. 2004;291:1238-1245JAMA. 2004;291:1238-1245

Preventable Deaths in Preventable Deaths in the U.S.the U.S.

U.S. ranks last among industrialized nations in preventable deaths

Could prevent 100,000 deaths annually if rates were similar to high-performing nations

Health Affairs, Sept. 2006

Mortality Amenable to Health CareMortality Amenable to Health CareU.S. Rank Fell from 15th to Last out of U.S. Rank Fell from 15th to Last out of

19 Countries19 Countries

7681

8884

89 89

99 9788

97

109 106

116 115 113

130134

128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fran

ceJa

pan

Aus

tral

iaSpa

in

Italy

Can

ada

Nor

way

Net

herla

nds

Swed

enG

reec

eA

ustr

iaG

erm

any

Finl

and

New

Zea

land

Den

mar

k

Uni

ted

Kin

gdom

Irela

ndPor

tuga

lU

nite

d Sta

tes

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.Source: Commonwealth Fund; E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71

Costs of Preventable Costs of Preventable DiseasesDiseases

We cannot effectively address escalating health We cannot effectively address escalating health care costs without addressing the problem of care costs without addressing the problem of chronic diseases and finding ways to delay or chronic diseases and finding ways to delay or prevent their onset.prevent their onset.

More than 90 million Americans live with chronic illnessMore than 90 million Americans live with chronic illness

Chronic diseases account for 70% of all deaths in the Chronic diseases account for 70% of all deaths in the U.S.U.S.

The medical costs of people with chronic diseases The medical costs of people with chronic diseases account for more than 75% of the nation’s approximately account for more than 75% of the nation’s approximately $1.5 trillion in annual medical care costs. $1.5 trillion in annual medical care costs.

Challenges in PreventionChallenges in Prevention Most important messages about prevention may Most important messages about prevention may

not be getting through to clinicians and patientsnot be getting through to clinicians and patients Not everything that Not everything that mightmight work work doesdoes work work Services should be supported by good evidence Services should be supported by good evidence

(but often aren’t) before they are widely (but often aren’t) before they are widely recommendedrecommended

Necessity of providing individual preventive Necessity of providing individual preventive services often skewed by: services often skewed by: Beliefs, anecdotal experiences of clinicians and patientsBeliefs, anecdotal experiences of clinicians and patients Inaccurate media messagesInaccurate media messages Advocacy groupsAdvocacy groups Political considerationsPolitical considerations

Primary care: is there time Primary care: is there time enough for prevention?enough for prevention?

Yarnall KS et al., Am J Public Health, Yarnall KS et al., Am J Public Health, 20032003

Used published and estimated times to Used published and estimated times to determine the total physician time determine the total physician time required to provide all recommended required to provide all recommended preventive services to a patient panel of preventive services to a patient panel of 2500 with an age and sex distribution 2500 with an age and sex distribution similar to that of the US populationsimilar to that of the US population

1773 hours annually, or 7.4 hours per 1773 hours annually, or 7.4 hours per working dayworking day

How much time do primary care How much time do primary care clinicians actually spend on clinicians actually spend on

preventive care?preventive care? Pollak KI et al., BMJ Health Serv Res, Pollak KI et al., BMJ Health Serv Res,

20082008 Data on family and internal medicine Data on family and internal medicine

visits from 2001-04 National Ambulatory visits from 2001-04 National Ambulatory Medical Care SurveyMedical Care Survey

Most time spent on: PSA (4.9 minutes), Most time spent on: PSA (4.9 minutes), cholesterol, Pap smear, mammograms, cholesterol, Pap smear, mammograms, exercise counseling, and blood pressureexercise counseling, and blood pressure

Spent less time than recommended on Spent less time than recommended on tobacco cessation (0.11 vs. 3 minutes) and tobacco cessation (0.11 vs. 3 minutes) and nutrition counseling (1.34 vs. 8.2 minutes) nutrition counseling (1.34 vs. 8.2 minutes)

Rethinking Current Health Rethinking Current Health ApproachesApproaches

Problem of Underuse of Problem of Underuse of Clinical Preventive ServicesClinical Preventive Services Insurance coverage makes a difference in Insurance coverage makes a difference in

whether people receive preventive serviceswhether people receive preventive services Approximately half (52%) of adults receive Approximately half (52%) of adults receive

preventive care according to guidelines for preventive care according to guidelines for their age and sex.their age and sex.11

In 2004, NCQA identified 48,600 cases of In 2004, NCQA identified 48,600 cases of late-stage breast cancer and colorectal late-stage breast cancer and colorectal cancer and osteoporosis-related fractures cancer and osteoporosis-related fractures that could have been averted if individuals that could have been averted if individuals received appropriate and timely preventive received appropriate and timely preventive care.care.22

Sources: 1. The Commonwealth Fund Commission on a High Performance Healthcare System, Sept 2006; 2. National Committee for Quality Assurance. The State of Healthcare Quality 2005. Washington, DC; NCQA: 2006.

Preventive Services in Preventive Services in Health ReformHealth Reform

Why Evidence-Based?Why Evidence-Based?

Need transparent, systematic Need transparent, systematic process to obtain and distill best process to obtain and distill best available evidence to support available evidence to support clinical decision making clinical decision making

Identifying, evaluating and Identifying, evaluating and summarizing scientific evidence about summarizing scientific evidence about outcomes or interventions or policiesoutcomes or interventions or policies

Translating research evidence into Translating research evidence into clinical practice recommendations clinical practice recommendations

General Attributes of Good General Attributes of Good Clinical Practice GuidelinesClinical Practice Guidelines

Comprehensive, systematic evidence searchComprehensive, systematic evidence search Evidence linked directly to recommendations via Evidence linked directly to recommendations via

strength of recommendation grading systemstrength of recommendation grading system Recommendations based on patient-oriented Recommendations based on patient-oriented

rather than disease-oriented outcomesrather than disease-oriented outcomes Development process is transparentDevelopment process is transparent Potential conflicts of interest identified and Potential conflicts of interest identified and

addressedaddressed Prospective validationProspective validation Clinical flexibilityClinical flexibility

U.S. Preventive Services U.S. Preventive Services Task Force: Prevention in Task Force: Prevention in the Clinical Settingthe Clinical Setting

What is the US What is the US Preventive Services Preventive Services

Task Force?Task Force? Congressionally mandated, independent Congressionally mandated, independent

panel of non-Federal experts in prevention panel of non-Federal experts in prevention and evidence-based medicine, established and evidence-based medicine, established in 1984in 1984

16 primary care clinicians (internists, 16 primary care clinicians (internists, pediatricians, family physicians, ob/gyns, pediatricians, family physicians, ob/gyns, nurses and health behavior specialists) nurses and health behavior specialists) appointed to rotating 4-year termsappointed to rotating 4-year terms

http://www.uspreventiveservicestaskforce.org/about.htm

What is the USPSTF What is the USPSTF Mission?Mission?

““to evaluate the benefits of individual to evaluate the benefits of individual [preventive] services based on age, [preventive] services based on age,

gender, and risk factors for disease; gender, and risk factors for disease;

make recommendations about which make recommendations about which preventive services should be preventive services should be

incorporated routinely into primary incorporated routinely into primary medical care and for which populations; medical care and for which populations;

and identify a research agenda for and identify a research agenda for clinical preventive care.”clinical preventive care.”

www.uspreventiveservicestaskforce.org/about.htm

Who Supports the Who Supports the USPSTF?USPSTF?

Administrative, research, technical and Administrative, research, technical and dissemination support provided by the Agency dissemination support provided by the Agency for Healthcare Research and Quality (AHRQ), for Healthcare Research and Quality (AHRQ), a division of the Department of Health and a division of the Department of Health and Human Services (DHHS)Human Services (DHHS)

Scientific support from AHRQ-funded Scientific support from AHRQ-funded Evidence-Based Practice Centers (EPCs)Evidence-Based Practice Centers (EPCs)

EPCs conduct systematic evidence reviews on EPCs conduct systematic evidence reviews on topics in clinical prevention that serve as the topics in clinical prevention that serve as the scientific basis for USPSTF recommendations scientific basis for USPSTF recommendations

www.uspreventiveservicestaskforce.org/about.htm

What are US Preventive What are US Preventive Services Services

Task Force Activities?Task Force Activities? Guidelines published in the form of Guidelines published in the form of

“recommendation statements”“recommendation statements” 2010 Affordable Care Act singles out 2010 Affordable Care Act singles out

positive recommendations by the USPSTF ( positive recommendations by the USPSTF ( “A” or “B”) for coverage without cost-“A” or “B”) for coverage without cost-sharingsharing

Recommendations are graded to convey Recommendations are graded to convey two major elements: certainty and two major elements: certainty and magnitude of net benefit of the preventive magnitude of net benefit of the preventive serviceservice

http://www.uspreventiveservicestaskforce.org/about.htm

The USPSTF Steps: The USPSTF Steps: Brief and GenericBrief and Generic

Step 1: Step 1: Define key questions and outcomes, Define key questions and outcomes, including anincluding an

analytic frameworkanalytic framework

(Note: CEA = carotid endarterectomy)(Note: CEA = carotid endarterectomy)www.uspreventiveservicestaskforce.org/uspstf07/methods/benefit.htm

The USPSTF Steps: The USPSTF Steps: Brief and GenericBrief and Generic

Step 2: Step 2: Define, retrieve and summarize Define, retrieve and summarize relevant evidence from the medical relevant evidence from the medical literatureliterature

Step 3: Step 3: Judge Judge qualityquality of individual studies: of individual studies:

good, fair, poorgood, fair, poor

Step 4: Step 4: Synthesize and judge the Synthesize and judge the adequacyadequacy of of the evidence about benefits and harms: the evidence about benefits and harms:

convincing, adequate, inadequateconvincing, adequate, inadequatewww.uspreventiveservicestaskforce.org/uspstf07/methods/benefit.htm

Systematic ReviewsSystematic Reviews A planned, comprehensive, reproducible, A planned, comprehensive, reproducible,

exhaustive review of the world’s literature on a exhaustive review of the world’s literature on a given topicgiven topic

Includes electronic resources (e.g., MEDLINE, Includes electronic resources (e.g., MEDLINE, EMBASE), experts and review of reference listsEMBASE), experts and review of reference lists

May include unpublished studies (but often does May include unpublished studies (but often does not, so ‘publication bias’ is always a concern)not, so ‘publication bias’ is always a concern)

Always valuableAlways valuable

The USPSTF Steps The USPSTF Steps

(continued):(continued): Step 5: Step 5: Determine and judge the Determine and judge the magnitudemagnitude of of

both both

benefits and harms: benefits and harms: substantial, moderate, substantial, moderate, small, zerosmall, zero

Step 6: Step 6: Determine and judge the Determine and judge the balancebalance of of benefits and harms (net benefit)benefits and harms (net benefit)

Step 7: Step 7: Judge the Judge the certaintycertainty of net benefit: of net benefit: low, low, moderate, highmoderate, high

Step 8: Step 8: Judge the Judge the magnitudemagnitude of net benefit: of net benefit: substantial, moderate, small, zero/negativesubstantial, moderate, small, zero/negative

Step 9: Step 9: Assign a letter grade: A, B, C, D, IAssign a letter grade: A, B, C, D, I.

www.uspreventiveservicestaskforce.org/uspstf07/methods/benefit.htm

Concept of “Net Benefit”Concept of “Net Benefit” Net Benefit = Benefits minus Harms of Net Benefit = Benefits minus Harms of

preventive servicepreventive service USPSTF recommends that clinicians USPSTF recommends that clinicians

routinely provide services that have routinely provide services that have strong evidence of large (“A”) or strong evidence of large (“A”) or moderate (“B”) net benefitmoderate (“B”) net benefit

USPSTF does not routinely recommend USPSTF does not routinely recommend services that provide small (“C”) or zero services that provide small (“C”) or zero (“D”) net benefit(“D”) net benefit

If unable to determine net benefit, TF If unable to determine net benefit, TF issues “I” (insufficient evidence) issues “I” (insufficient evidence) statementstatement

USPSTF Grades of USPSTF Grades of RecommendationsRecommendations

Certainty of Certainty of Net BenefitNet Benefit

Magnitude of Net BenefitMagnitude of Net Benefit

SubstantSubstantialial

ModeratModeratee

SmallSmall Zero/Zero/negativenegative

HighHigh AA BB CC DD

ModerateModerate BB BB CC DD

LowLow InsufficientInsufficient

Accessing Prevention Accessing Prevention Guidelines at the Point of Guidelines at the Point of

CareCare Annual pocket-sized Annual pocket-sized Guide to Clinical Guide to Clinical

Preventive ServicesPreventive Services

www.uspreventiveservicestaskforce.orgwww.uspreventiveservicestaskforce.org

Web-based and PDA Web-based and PDA Electronic Preventive Electronic Preventive Services Selector Services Selector (ePSS)(ePSS)

www.healthfinder.gov (for patients) Essential Evidence Plus online and mobile

resource American Family Physician journal

ePSS app for smartphonesePSS app for smartphones

ePSS app for smartphonesePSS app for smartphones

Contending with Contending with “prevention for “prevention for

profit”profit”Not everything that Not everything that mightmight

work does work – that’s why work does work – that’s why guidelines require evidence!guidelines require evidence!

An advertisement in my An advertisement in my church’s bulletin earlier church’s bulletin earlier

this yearthis year Life Line Screening, the nation's leading provider of Life Line Screening, the nation's leading provider of

preventive health screenings, will offer their preventive health screenings, will offer their affordable, non-invasive, painlessaffordable, non-invasive, painless health health screenings.screenings.

Five screenings will be offered that scan for Five screenings will be offered that scan for potential health problems related to: potential health problems related to: blocked blocked arteriesarteries, which is a leading cause of stroke; , which is a leading cause of stroke; abdominal aortic aneurysmsabdominal aortic aneurysms, which can lead to a , which can lead to a ruptured aorta; ruptured aorta; hardening of the arteries in the hardening of the arteries in the legslegs, which is a strong predictor of heart disease; , which is a strong predictor of heart disease; atrial fibrillationatrial fibrillation or irregular heart beat, which is or irregular heart beat, which is closely tied to stroke risk; and a closely tied to stroke risk; and a bone density bone density screeningscreening, for men and women, used to assess the , for men and women, used to assess the risk of osteoporosis. risk of osteoporosis.

Register for a Wellness Package with Heart Rhythm Register for a Wellness Package with Heart Rhythm for $149. Add Disease Risk Assessment with blood for $149. Add Disease Risk Assessment with blood testing & biometrics for $79 more.testing & biometrics for $79 more.

Sounds good … but Sounds good … but what does the what does the evidence say?evidence say?

USPSTF Systematic Reviews,USPSTF Systematic Reviews,

2005 through 20102005 through 2010

Stroke screenings? Just Stroke screenings? Just say nosay no

"Blocked arteries" / stroke screening is most "Blocked arteries" / stroke screening is most likely a carotid ultrasound scan, which likely a carotid ultrasound scan, which doesn't help because most patients with doesn't help because most patients with asymptomatic carotid artery blockages will asymptomatic carotid artery blockages will not suffer strokes. Although the screening not suffer strokes. Although the screening test is "non-invasive and painless," the test is "non-invasive and painless," the confirmatory test, angiography, is not (it confirmatory test, angiography, is not (it actually causes a stroke in a small number of actually causes a stroke in a small number of patients) and unnecessary carotid patients) and unnecessary carotid endarterectomy can lead to death.endarterectomy can lead to death.

AAA screening? Not for AAA screening? Not for most peoplemost people

Abdominal aortic aneurysm screening is Abdominal aortic aneurysm screening is only recommended in men ages 65 to 75 only recommended in men ages 65 to 75 who have ever smoked, because who have ever smoked, because aneurysms are much less common in aneurysms are much less common in younger, female, and non-smoking younger, female, and non-smoking populations. Even in men who are populations. Even in men who are eligible for the test, it's important to eligible for the test, it's important to weigh the potential benefits against the weigh the potential benefits against the potential harms of corrective surgery, potential harms of corrective surgery, which has a not insignificant mortality which has a not insignificant mortality rate itself.rate itself.

Pass on screening for Pass on screening for PVDPVD

"Hardening of the arteries in the "Hardening of the arteries in the legs," or screening for peripheral legs," or screening for peripheral vascular disease with an arterial-vascular disease with an arterial-brachial index, hasn't been proven to brachial index, hasn't been proven to prevent heart attacks but will prevent heart attacks but will certainly lead to many false positive certainly lead to many false positive results.results.

Screening for atrial Screening for atrial fibrillation? Are you kidding fibrillation? Are you kidding

me?me? I've never even heard of atrial I've never even heard of atrial

fibrillation (irregular heart beat) fibrillation (irregular heart beat) screening, which I presume is doing screening, which I presume is doing a screening EKG, which is also a screening EKG, which is also totally unproven. Absolutely no totally unproven. Absolutely no organizations recommend this.organizations recommend this.

Even “good” screening tests Even “good” screening tests should be cleared by should be cleared by

cliniciansclinicians Screening for osteoporosis with bone Screening for osteoporosis with bone

density testing is the only test on the list density testing is the only test on the list that's actually worthwhile for a large that's actually worthwhile for a large number of adults, especially women over number of adults, especially women over 65. But it's not appropriate to do this test 65. But it's not appropriate to do this test without a prior consultation with a clinician without a prior consultation with a clinician who can discuss the risks and benefits of who can discuss the risks and benefits of undergoing this type of screening. And undergoing this type of screening. And there are still questions about whether men there are still questions about whether men benefit to the same degree as women, or at benefit to the same degree as women, or at all.all.

The Bottom LineThe Bottom Line Preventive services have great potential Preventive services have great potential

to improve national health outcomesto improve national health outcomes An evidence-based process is critical to An evidence-based process is critical to

select services of value and discourage select services of value and discourage ineffective and/or harmful testsineffective and/or harmful tests

That process is based upon a careful, That process is based upon a careful, systematic search of the medical systematic search of the medical literature on a topicliterature on a topic

Clinicians have many options for Clinicians have many options for accessing prevention guidelines at the accessing prevention guidelines at the point of carepoint of care

Thank you!Thank you!

Questions?Questions?