Will Docs Go Where Evidence Leads?

The number of physicians doing screenings that aren't recommended -- and getting paid for it -- is simply depressing.

The U.S. Preventive Services Task Force recommends -- based on an evidence report -- that annual screening for cervical cancer is unnecessary. Yet, scores of women who had a Pap smear last year will be getting a reminder from their physician to schedule another one this year.

Why?

Some physicians continue to do some tests more often than is needed -- and others that are of questionable value -- out of fear. Certain screenings are expected by patients and their families. So we do it, lest we expose ourselves to the threat of a lawsuit when a patient gets sick -- or worse.

Some docs likely do it, against their better judgment, at a patient's request.

And perhaps some of us just aren't paying attention to the evidence.

Ah, evidence. Facts. We remember those, yes? People don't always like them. They can be quite a nuisance.

Here's a good one. In 2008, breast cancer was overdiagnosed in more than 70,000 U.S. women, or nearly one-third of all breast cancer diagnoses. In a 30-year period, more than 1 million American women were overdiagnosed, according to a study (abstract) in the New England Journal of Medicine.

Researchers found that "despite substantial increases in the number of cases of early-stage breast cancer, screening mammography has only marginally reduced the rate at which women present with advanced cancer." Screening, they said, is having "at best, a small effect on the rate of death from breast cancer."

Mammography is just the tip of the iceberg. It has been estimated that our health care system spends $280 billion a year on services for which the risks exceed the known benefits.

Another recent study found that Medicare spends more than $400 million a year for screening women 75 or older for breast cancer. That staggering number is spent despite findings by the USPSTF and the AAFP that have said there is not sufficient evidence to assess the benefits and harms of screening women in that age group.

Of course, breast cancer is a sensitive subject. Just ask the USPSTF.

When, in 2009, the task force issued recommendations against routine screening mammography for women in their 40s who aren't at increased risk for breast cancer, there was no shortage of outrage. The task force -- experts in prevention and evidence-based medicine who volunteer their time to make recommendations for their primary care colleagues -- were attacked in the media, criticized by subspecialists, had their motives and qualifications called into question by some, and finally, were called to explain themselves in front of a House subcommittee.

It wasn't pleasant.

So the task force changed its process, added a public comment period and became more transparent. Yet this group -- which considers evidence and outcomes, not costs -- continues to take a public beating when its evidence-based recommendations go against an established practice, such as prostate-specific antigen (PSA)-based screening.

The PSA has more harms than benefits, but many patients believe in, and want, that test. All we can do is explain the pros and cons and work with them -- in other words, have an informed discussion.

That, of course, requires us to be informed ourselves. Busy physicians don't have the time to read every evidence report, recommendation and study, so it's important to have trusted sources that use sound methodology and evidence-based research. The USPSTF is the gold standard. Over time, it's repeatedly been proven right. For example, when others were recommending hormone replacement therapy, the task force said evidence was lacking.

The AAFP also uses an evidence-based approach. The Academy's Commission on Health of the Public and Science reviews recommendations from the USPSTF and the CDC's Advisory Committee on Immunization Practices, as well as guidelines crafted by other professional medical organizations.

The Academy's resources for clinical preventive services and clinical recommendations go through painstaking review processes for the benefit of members and our patients.

Another source that could become a tremendous resource and benefit for primary care physicians is the Patient-Centered Outcomes Research Institute, (PCORI), which strives to provide doctors and patients with a better understanding of treatment options available. PCORI may become for treatment what the USPSTF is for prevention.

But the question remains: Will evidence-based medicine work? Will physicians follow where the evidence leads?

Last year, the AAFP released a list of five tests and treatments that family physicians should think twice about before performing, ordering or prescribing as part of a national campaign called Choosing Wisely. A new list of five more tests and treatments to carefully ponder will be released later this month in a second phase of that campaign.

Providing the best care and reducing costs in the system requires us to follow the evidence. Sadly, in our fee-for-service world, physicians have incentives to continue to provide services that will be paid for even if the science behind those services is lacking. And barring tort reform, others will feel compelled to keep ordering tests they don't necessarily trust.

What will you do for your patients?

Related ANN Coverage
Overuse, Misuse of Certain Ambulatory Medical Services Increasing
Progress Made in Boosting Underused Services, Study Finds
(2/19/2013)