Researchers suggest it might be time for some ‘de-intensification’
Does anybody actually oppose the concept of preventive medicine for kids and adults? Ask yourself: How many people do you know who believe that regular blood pressure checks at the pediatrician’s office or annual well-woman visits are bad?
Yet in a research report and accompanying editorial in JAMA Internal Medicine this fall, clinicians from the University of Michigan and elsewhere raised a red flag: They ask, Have we reached a point where providers have too many guidelines to keep track of, including those pertaining to preventive care? When professional societies or governmental agencies add recommendations to their guidelines, do they remove others of lesser value? Is it time to “de-intensify” preventive care guidelines?
“Much of health care involves established, routine, or continuing use of medical services for chronic conditions or prevention,” write the authors of “Identifying Recommendations for Stopping or Scaling Back Unnecessary Routine Services in Primary Care.” “Stopping some of these services when the benefits no longer outweigh the risks (e.g., owing to older age or worsening health) or when there is a change in the evidence that had previously supported ongoing treatment and monitoring, presents a challenge for both clinicians and patients and is rarely done successfully even when evidence favors cessation.”
Personalize preventive care
“If we don’t work to get healthier as a nation, we will not be able to afford our healthcare,” says Eva Chalas, M.D., FACOG, FACS, president of the American College of Obstetricians and Gynecologists. “The steady and rather dramatic rise in healthcare cost is unsustainable.
“Prevention is truly worth a pound of cure,” she says. “Unfortunately, most Americans take better care of their cars and pets than their health. The obesity epidemic – which is responsible for the development of many other conditions, including hypertension, heart disease, type 2 diabetes, cancer and musculoskeletal diseases, amongst others – continues to be on the rise. We must convince our populations to engage in healthier lifestyles, and that medications are not a substitute for lifestyle changes.”
Preventive care guidelines can help, but “we should not practice ‘one size fits all’ medicine,” says Chalas. “I believe that preventive care should be personalized and as such, based on each patient’s risk factors to develop a particular condition.” In this, she agrees with the JAMA researchers, who advise against performing annual cardiac testing in individuals at low risk for cardiovascular disease.
“Gaps in health care of our patients continue to exist, and we need to find ways to engage them in their healthcare to minimize risk of development of chronic diseases, such as obesity, type 2 diabetes, hypertension, heart disease and cancers related to inherited deleterious mutations. Because obstetricians and gynecologists care for their patients across their lifespan, we are uniquely positioned to predict the risk of development of these conditions, since many initially occur in pregnancy, and help patients mitigate these risks.
“I believe that in the future, we will be using genetic information to identify risk factors for chronic diseases at birth, and working with parents and pediatricians on mitigation strategies,” she says.
‘Clear and unambiguous’
Suzanne Berman, M.D., a pediatrician in Crossville, Tennessee, and chair of the American Academy of Pediatrics’ Section on Administration and Practice Management, agrees with the JAMA authors that subtracting one preventive care guideline for every new one that’s added isn’t a bad idea. But it’s not always possible, particularly with pediatrics. It’s difficult to characterize any pediatric preventive-care guidelines as non-essential, as they may add decades – not merely months or years – of healthy living to kids’ lives, she says.
But like the JAMA authors, Berman believes that guidelines – whether for prevention or therapy – must be clear and unambiguous. “A guideline that says ‘Avoid use of drug X for condition Y’ is too vague,” she says. “What does ‘avoid use’ mean?” Does it mean never use the drug for that condition, or does it mean only use it under certain circumstances? And are those circumstances clearly defined?
AAP policy-writers of the organization’s Bright Futures preventive care guidelines strive for precision, she points out. First launched in 1994 and updated regularly, Bright Futures offers a schedule of recommended preventive services for children, and it forms the basis for Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program.
Berman points out one more difficulty associated with guidelines: It can take a long time – years, in fact – for new ones to become standard practice. For example, a study may show incontrovertibly that early supplementation of iron for babies with anemia improves outcomes, yet years may pass before the majority of pediatricians are onboard. Perhaps it’s force of habit on the part of physicians or even insurers, or simply the fact that it takes time for the majority of clinicians to become aware of new guidelines, let alone integrate them into their practices.
At the same time, years may pass before the majority of doctors finally abandon practices that have been discredited. “We sometimes shake our heads and ask, ‘How can people still be doing that?’” she says. “After all, we are supposed to learn how to continually evaluate medical evidence.” But doctors are busy, they have their families and friends, or they may simply fail to stay current with certain protocols if they rarely see patients to which they apply.
“Preventative care is an integral and important part of family medicine,” says Amy Mullins, M.D., medical director for quality and science, American Academy of Family Physicians. “Screening for disease, then altering the course of that disease if needed, is life-changing for patients and ultimately saves the health care system dollars.
AAFP supports the use of evidence-based medicine, she adds. “This involves all aspects of medicine and is necessarily complex, complicated, and requires the use of many different guidelines.”
The AAFP reviews recommendations put forth by the United States Preventive Services Task Force (USPSTF) and the CDC’s Advisory Committee on Immunization Practices (ACIP), and either chooses to agree or disagree with their recommendations, says Mullins. “We also review guidelines from other medical organizations and either endorse, provide an affirmation of value, or do not endorse.
“Guidelines are routinely updated, and some are retired, as are the quality measures that are typically developed using the guidelines. The USPSTF and ACIP recommendations are also routinely updated. The AAFP utilizes a specific methodology for developing clinical practice guidelines based on available evidence and patient preferences.”
Preventive care guidelines: Resources
- Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention, www.cdc.gov/vaccines/acip/index.html
- Bright Futures, American Academy of Pediatrics,
- Clinical Preventive Services Recommendations, American Academy of Family Physicians, www.aafp.org/family-physician/patient-care/clinical- recommendations/clinical-practice-guidelines/clinical-preventive-servic- es-recommendations.html
- Comparative Guideline Tables, American College of Physicians, www.acponline.org/clinical-information/guidelines/comparative- guideline-tables. (Summaries of recommendations from a variety of U.S. and international organizations regarding controversial topics in screening, prevention and management. Available to ACP members.)
- Women’s Preventive Services Initiative (WPSI), American College of Obstetri- cians and Gynecologists, www.womenspreventivehealth.org/about
- U.S. Preventive Services Task Force, www.uspreventiveservicestaskforce.org/uspstf