2/23/2017 US Preventive Services Task Force and guidelines - - PowerPoint PPT Presentation

2/23/2017 1 US Preventive Services Task Force and guidelines addressing the needs of underserved communities

Kirsten Bibbins-Domingo, PhD, MD, MAS Chairperson, USPSTF Lee Goldman, MD Endowed Chair in Medicine Professor of Medicine and of Epidemiology & Biostatistics University of California, San Francisco

Disclosure:

I have been a member of the US Preventive Services Task Force since 2010 and I am the current Chair of the USPSTF.

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Outline

• Review the procedures of the US Preventive Services

Task Force.

• Understand the importance and challenge in making

recommendations tailored to needs of diverse and underserved communities.

• Explore our current approaches in the context

several recent recommendation.

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The U.S. Preventive Services Task Force (USPSTF)

• Independent panel of volunteer, non-federal experts (N=16)
• Makes recommendations on clinical preventive services offered in the

primary care setting

• Screening tests
• Preventive medications,
• Counseling
• Recommendations apply to asymptomatic patients – without signs of

symptoms of disease.

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Steps the USPSTF Takes to Solicit Input & make a Recommendation

Topic Nomination At each stage – 1) Solicit feedback from content experts, sub-specialists 2) Draft posted for public comment 3) Peer-review of evidence report prior to public posting

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Basic USPSTF Methods for Developing Recommendations Assess the evidence across the analytic framework for:

• The certainty of the estimates of the potential

benefits and harms

• The magnitude of the potential benefits and harms
• The balance of the benefits and harms, or the

magnitude of the net benefit of the preventive service

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Basic USPSTF Methods for Developing Recommendations: The Letter Grades

Certainty of Net Benefit Magnitude of Net Benefit Substantial Moderate Small Zero/Negative High A B C D Moderate B B C D Low I

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USPSTF Grades

• A
• B
• C
• D
• I

All three grades are recommendations in favor of screening They differ by the level of certainty of the evidence and the magnitude of potential net benefit Not enough evidence to make a recommendation NOT a recommendation against screening – rather it’s a call for more research No net benefit and recommend against screening

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USPSTF Grades and the Affordable Care Act

• Private insurers “…shall provide coverage for and shall not

impose any cost sharing requirements for evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the USPSTF”

• The law also states “…nothing in this subsection shall be

construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by USPSTF or to deny coverage for services that are not recommended by the Task Force”

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USPSTF Grades and the Affordable Care Act

• The ACA expands access to evidence-based preventive services,

but is the “floor” and not the “ceiling” for coverage

• USPSTF evaluates science, but does not determine coverage -

that role is left to insurers, regulators, and lawmakers

• As physicians, we value access for our patients, but as a Task

Force, we cannot reinterpret the science to arrive at an A or B recommendation

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Working to make recommendations useful to all communities in the US

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Why?

• Equity
• Assuring the health of all Americans
• Health and Healthcare disparities
• Addressing communities disproportionately affected by disease
• Variation
• High quality care
• Limit unnecessary variation,
• Pay attention to necessary variation

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The tension

• How much more incremental evidence do we need to

make a different recommendation for a particular group?

• How do we balance the important goal of calling for more

research in under-studied groups, with the desire for a specific recommendation for a particular group?

• How do we communicate this complexity in a way that is

useful for patients and clinicians?

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Considering diverse communities at each step

Topic Nomination

• Engaging stakeholder groups to provide comments at each step
• Continuing to advance methodologies regarding heterogeneity in the evidence review
• Enhanced communication in our final products

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• 1. Communicating “Who is at risk?”

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Providing more detail on who to screen for syphilis

The USPSTF recommends screening for syphilis in persons who are at increased risk for infection. Based on 2014

surveillance data, men who have sex with men (MSM) and men and women living with HIV have the highest risk for syphilis infection; 61.1% of cases of primary and secondary syphilis occurred among

MSM, and approximately one-half of all MSM diagnosed with syphilis were also coinfected with HIV. One study found that rates

• f syphilis coinfection were 5 times higher in MSM living with HIV compared with men living with HIV who do not have sex with

men.4 Based on older study data from northern California, the adjusted relative risk for syphilis infection in persons living with HIV (vs those without HIV) was 86.0 (95% CI, 78.6 to 94.1); 97% of those living with HIV and with incident syphilis were male.5

When deciding which other persons to screen for syphilis, clinicians should be aware of the prevalence of infection in the communities they serve, as well as other sociodemographic factors that may be

associated with increased risk of syphilis infection. Factors associated with increased prevalence that clinicians should consider include history of incarceration, history of commercial sex work, certain racial/ethnic groups, and being a male younger than 29 years, as well as regional variations that are well described. Men accounted for 90.8% of all cases of primary and secondary syphilis in 2014. Men aged 20 to 29 years had the highest prevalence rate, nearly 3 times higher than that in the average US male population.1 Syphilis prevalence rates are also higher in certain racial/ethnic groups (among both men and women); in 2014, prevalence rates of primary and secondary syphilis were 18.9 cases per 100,000 black individuals, 7.6 cases per 100,000 Hispanic individuals, 7.6 cases per 100,000 American Indian/Alaska Native individuals, 6.5 cases per 100,000 Native Hawaiian/Pacific Islander individuals, 3.5 cases per 100,000 white individuals, and 2.8 cases per 100,000 Asian individuals.1 The southern United States comprises the largest proportion of syphilis cases (41%); however, the case rate is currently highest in the western United States (7.9 cases per 100,000 persons). Metropolitan areas in general have increased prevalence rates of syphilis.1 Risk factors for syphilis often do not present independently and may frequently overlap. In addition, local prevalence rates may change over time, so clinicians should be aware of the latest data and trends for their specific population and geographic area. 19

• 2. Balancing the call for more research,

with providing clinicians useful information for their practice

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Abnormal blood glucose and Type 2 diabetes: Screening

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Abnormal blood glucose and Type 2 diabetes: Screening

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What appears on our website

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• 3. Important disparities may not

necessarily be alleviated by increased screening

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The interests in clinical prevention are many, significant, and complex.

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Impact of Race on Effectiveness of Mammography Screening

• African American women are more likely to die of breast cancer than white

women (31 v. 22 deaths per 100,000 women per year)

• Reason for the disparity not entirely clear:
• Biology: African American women more likely to develop triple-negative

phenotypes and other aggressive tumors

• Socioeconomic: Associations between being African American and

experiencing delays in receipt of health care services for cancer (even lack of treatment altogether)

• African American women severely underrepresented in the RCTs of

screening (largely performed in Europe in white women)

• Direct evidence is lacking for this population and this represents a critical

research need

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• 4. But some disparities will absolutely

be addressed by increased screening

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• 5. The call for more research is

important

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Annual Report to Congress

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Influencing a research agenda

The USPSTF found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death. The USPSTF found no existing studies that determine the accuracy of screening tools for identifying family and intimate partner violence among children, women, or older adults in the general population. The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed(see Clinical Considerations). The USPSTF found limited evidence as to whether interventions reduce harm to women and no studies that examined the effectiveness of interventions in older adults. No studies have directly addressed the harms of screening and interventions for family and intimate partner

• violence. As a result, the USPSTF could not determine the balance between the benefits

and harms of screening for family and intimate partner violence among children, women, or older adults. 2 March 2004, Vol 140, No. 5

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Conclusions

• The USPSTF is an independent entity that uses a structured

systematic review of the scientific evidence to make recommendations about preventive services offered in primary care.

• We strive to assure our recommendations are tailored to

addressing the needs of all populations in the US, particularly those disproportionately affected by disease.

• Please stay engaged with us in our process. We value and utilize

input from individuals and organized stakeholders throughout our process.