When the integrity of the U.S. Preventive Services Task Force (USPSTF) came under fire during the recent annual meeting of the AMA House of Delegates here, the AAFP delegation staunchly defended the task force's standing as "an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services or preventive medications."
Two measures that came before the AMA Reference Committee on Science and Technology June 17 aimed to compel the USPSTF to incorporate subspecialist input into its screening recommendations, including its controversial 2009 stance on routine mammography in women younger than 50 and its more recent recommendation against the use of prostate-specific antigen (PSA) testing as a routine screen for prostate cancer.
One resolution directed the AMA to seek legislative and/or regulatory means to require the USPSTF to consult with relevant subspecialty groups "when considering recommendations for a specific disease condition" and to express a lack of confidence in the task force's recommendations unless they reflect that subspecialist input. The second specifically asked the AMA to reject the USPSTF's recommendation on PSA screening "until conflicting evidence can be properly reconciled by the appropriate (sub)specialty" and to meet with the USPSTF to establish a protocol for including subspecialist physicians as consultants.
- Two measures considered during the 2012 meeting of the AMA House of Delegates aimed to compel the U.S. Preventive Services Task Force (USPSTF) to incorporate subspecialist input into its recommendations.
- In testimony during an AMA reference committee hearing, AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, supported the task force pointing to USPSTF's rigorously evidence-based recommendations.
- Despite testimony outlining the multiple stages at which subspecialists can and do provide input, delegates adopted a substitute resolution that "expresses concern" about the task force's recommendations on routine screening mammography and prostate-specific antigen testing.
In testimony during the reference committee hearing, AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, explained that, years ago, the AAFP recognized a need to respond to members' calls for guidance in the face of multiple, often conflicting screening recommendations.
"Back then, we made a decision to endorse and support the USPSTF recommendations," Goertz told reference committee members, a judgment he said was based on the task force's consistent use of the best available evidence in making its recommendations on screening, counseling and other preventive services.
"The problem occurs when others use these recommendations or guidelines to deny or approve payment, particularly if there are problems getting needed exceptions through or when a recommendation differs from others' recommendations."
Capt. Marcel Salive, M.D., M.P.H., of the U.S. Public Health Service, also came to the task force's defense, assuring the reference committee that the processes the USPSTF follows are transparent.
"There are multiple stages at which (sub)specialists can and do provide input," he said, further noting that a number of organizations, including the AAFP, the American Congress of Obstetricians and Gynecologists and the American College of Physicians, regularly send representatives to task force meetings.
A report from the AMA Council on Science and Public Health provoked lengthy discussion both before and during the 2012 annual meeting of the AMA House of Delegates in Chicago.
Spurred by the U.S. Preventive Services Task Force (USPSTF) 2009 recommendation to individualize decisions about screening mammography in women ages 40 through 49 rather than routinely perform the screening in these patients, the council report(www.ama-assn.org) (pp. 33-62 of 114-page PDF) details current screening mammography guidelines from various entities, explores the benefits and harms of mammography, reviews the process by which the USPSTF revised its recommendations on screening mammography, and updates the AMA's current policy on the topic.
Of particular significance was the council report's statement that "at age 40, all women should be eligible for screening mammography." The AMA's previous policy on screening mammography, which this report supplanted, recommended "annual screening mammograms and continuation of clinical breast examinations in asymptomatic women 40 years and older."
After 15 minutes of floor debate, the Michigan State Medical Society delegation tried but failed to replace the council's eligibility phrasing with more prescriptive language stating that women 40 and older "should undergo" screening mammography; in the end, the delegates voted to adopt the council report's recommendations.
Others, however, assailed the USPSTF and its recommendations. Much of the testimony focused on the PSA screening issue, as delegates relayed anecdote after anecdote about a patient or relative whose "life was saved by PSA screening."
In its report(www.ama-assn.org) (pp. 24-26 of 35-page PDF), the reference committee acknowledged the impassioned testimony on both sides of the issue and sought to bridge the divide by offering a substitute resolution in which the AMA "expresses concern" about the task force's recommendations on routine screening mammography and PSA testing and their effects on access to preventive care. The substitute measure also called for the AMA to "encourage the USPSTF to implement procedures that allow for meaningful input on recommendation development from specialists and stakeholders in the topic area under study."
Finally, the committee recommended reaffirmation of existing AMA policies related to the topic, including one that "encourages governmental panels and task forces dealing with specific disease entities to have representation by physicians with expertise in those diseases."
Despite the exhaustive reference committee testimony, the debate continued during the House of Delegates' June 19 business session, with many of the same speakers reiterating their previous remarks.
"There will be thousands of men who are going to be killed by this (PSA screening) recommendation, who won't get the care they need," warned urologist Jeff Terry, M.D., a delegate from the Medical Association of the State of Alabama.
"The issue is that this organization's decisions carry significant weight," said American College of Radiology delegate Albert Blumberg, M.D. "I anticipate as a practicing radiation oncologist that there will be patients who will be denied … coverage for screening PSA because it has a D recommendation now from (the USPSTF)."
AAFP member Timothy Beittel, M.D., of Thomasville, N.C., an alternate delegate from the North Carolina Medical Society, however, pointed out that what the USPSTF gave a D recommendation to is routine PSA screening. "(The task force) in no way said it should not be done on any man and, in fact, specifically said that it should be discussed by the physician with their patient to take into account individual factors."
A final vote came only after nearly 40 minutes of discussion on the floor of the AMA house, with delegates eventually adopting the substitute measure's somewhat milder language in lieu of the two original resolutions.