The USPSTF should stay independent from politics

The United States Preventive Services Task Force (USPSTF) is a federal committee composed of private sector experts in prevention and primary care. Its mandate is to make recommendations as to which preventive services are beneficial, which are useless and which are harmful. Disconcertingly, there is a small but vocal opposition to the USPSTF as embodied by an op-ed piece in the Wall Street Journal by Dr. Scott Gottlieb.

Dr. Gottlieb’s main argument against the USPSTF is that it sets too high a bar for evidence to demonstrate that a particular test or intervention is beneficial and that it is out of sync with conventional medical practice. At the same time, because its recommendations for preventive services must be covered by insurance companies, it represents an insidious power grab by the Obama administration.

This smear against the USPSTF is baseless for a number of reasons. First, the USPSTF recommendations are valuable precisely because the bar for the evidence is high. Primary care physicians know that these recommendations are built on a solid foundation of evidence and so when services are recommended, those graded A or B, we know that we should offer them to our patients to improve their health. Requiring that insurance companies cover these services at no cost to patients ensures that money is not a barrier to getting beneficial preventive services.

Second, conventional medical practice is not synonymous with quality medical care. A study in the Annals of Internal Medicine published this month shows that 28% of physicians would screen women at low risk for ovarian cancer.  This is despite the fact that no professional society recommends ovarian cancer screening and that the USPSTF finds that the potential harms outweigh the benefits. In general, some conventional practices not grounded in evidence are later found to be beneficial while others are later found to be useless or harmful. This uncertainty may not sit well with many but it is the reality of how medical knowledge unfolds.

Third, there is nothing wrong with health plans dropping coverage for services that don’t have an A or B from the USPSTF. Insurance companies would be wise to not cover services that don’t provide benefit to their patients or worse, have the potential to harm them. To further scaremonger this point, Dr. Gottlieb warns that the USPSTF will at some point recommend against services that people now take for granted. I too am sure this will happen but I’m not sure why it’s a bad thing. If new evidence reveals that what we’re doing is useless or harmful, wouldn’t we want to stop what we’re doing?

Lastly, Dr. Gottlieb’s solution for the “problem” of the USPSTF’s structure is to open it up to political considerations. The USPSTF recommendations are respected precisely because they are perceived as being based on solid evidence and not on political considerations. The panel members are private sector experts, not political appointees or government employees. While politics may influence ultimate decisions on health insurance coverage, they have no place in a careful assessment of medical best practices.

The USPSTF is a well respected body whose recommendations form the basis of preventive care services in the United States. Casting a sinister shadow on the actions of the USPSTF may serve to further his political agenda but it has no place in the practice of good medicine.

Nilesh Kalyanaraman is a physician who blogs at Progress Notes.

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  • http://twitter.com/C4MyOwnTerms Jared A. Chambers

    So, his argument is that the body has been manipulated by those who bring politics into it, and yours is “How dare you bring politics into this?!”

    As to the facts, I think more need to be seen from both sides to render a final verdict.  But, the fallacy in dismissing an argument against political motivations based on opposite political motivations is apparent.  It’s a tautology.  If I am offended by the politics I see presented, then of course I must have an opposite, but equally political, point of view.  To point that out is obvious but doesn’t rebut the original point.

    Governmental bodies are inextricably linked to politics.  To simply dismiss someone for worrying that a political view they oppose is corrupting the process by saying their political view that you oppose is corrupting the process is a schoolyard exercise in, “I know you are, but what am I?!”  Since this is not PeeWee’s Playhouse, the argument presented is not very credible because it dismisses an argument worth discussing by questioning the motives (insertion of politics) of the opponent… which may have made some sense if he were doing anything other than pointing out that politics were already in play.

    • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

      Gottlib claims that the body has been manipulated by politics – this isn’t a fact, it’s his claims.

      He also says that the bar is set to high, but why shouldn’t it be? Tests have benefits and harms just as “preventive” interventions. Just because doctors choose to ignore the fact that tests can harm healthy people and order every test in the book doesn’t mean it’s true.

      There needs to be an organization that is unbiased and that can evaluate data. The disease advocacy organizations usually are biased and they also get donations from corporations that benefit from interventions, so they are biased too.

      USPSTF is the most unbiased organization there is. It’s well respected, it also publishes not only its recommendations but rationale for them which reasonable people can read and make their own decisions.

      • http://twitter.com/C4MyOwnTerms Jared A. Chambers

        “I think the USPSTF displays political bias,” says one.

        “No it’s not biased!  You’re politically biased!” is the retort.

        Again, it just might be a worthy debate.  And merely shouting down the person making the claim by mirroring the same claim back against their claims is something of a schoolyard debate that only lends credence to the original charge.  In this manner that this is going, no one can ever make an accusation about political bias without being accused of equal but opposite political bias.  That this has been a core argument of the left during every meaningful discussion about media, culture, race, gender, etc. only raises a red flag that perhaps the USPSTF may be used by the left, as the original charge stated.  I’m not convinced wither way, but I know it deserves a more serious discussion than, “No, you’re wrong, and all the people on my side also think you’re wrong.”  Be serious.

        • http://twitter.com/C4MyOwnTerms Jared A. Chambers

          PS:  Show me someone or a group of someones without political bias, and I will show you a someone or group of someones who are arrogant enough to think their opinions are actually facts, and anyone who disagrees is just an ignorant hack.  The best we can ever accomplish is having an open sharing of diverse opinions to get about an unbiased OUTCOME.  But to pretend bias doesn’t exist and refuse to discuss the point without accusations of being persecuted by bias is not productive.

          • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

            This is what we are doing here – debating. You can argue with USPSTF confusion – fine, but if you remove USPSTF you have nothing but disease advocacy organizations who at best cannot see past their disease and emotional involvement and at worst get money from companies with conflict of interest. USPSTF is comprised of many different doctors/epidemiologists, etc. presumably with differing political views.

            The standards of USPSTF haven’t changed regardless of which political party was in office. The only thing that is changed is that right now every unpopular recommendation with regards to less screening get viewed through the prism of health care reform.

            You can always argue with specific recommendations if you don’t agree with them, but as I patient I want to be able to see them. I cannot trust doctors not to over-test.

          • Anonymous

            As a patient, it is/would be futile to argue with the specific recommendations as those recommendations for less treatment are embraced by health insurance.  Health care treatment is based on the opinions of only 16 people serving on the USPSTF.  One of their decisions is to put off pap smears because cervical cancer is a “slow grower and we can catch it next time”.  I do not think this is in a woman’s best interest.  I, for one, do not want my MD to UNDER test or UNDER treat.

  • Sarah Wells

    What’s good for a herd isn’t necessarily good for an individual.   USPSTF is subject to politics so long as what is good for the herd is seen as a government imperative.  USPSTF  should be recommendation neutral,  gather information and list pros and cons only.   Doctors and patients ALONE then decide what benefits are desirable in view of risks.  Insurance shouldn’t pay for routine care or “screening” anyway – routine care and health checks should be strictly a private affair.

  • Anonymous

    Unfortunately it’s because “Primary care physicians know that these recommendations are built on a solid foundation of evidence” there is a problem.  As a mammographer, I’ve read extensively about the USPSTF recommendations.  They created non-peer reviewed data from decades old studies using a computer model (with the lowest estimate of reduced mortality from mammography of 15% used compared to a high of 54%), then chose to ignore their own “data” when it confirmed mammograpghy screening begining at 40 significantly improves survival of more women.  Instead they focused on the “harms” of screening outweighing the benefit of saving lives.  Not one breast specialist was on the panel.

    I agree there are limitations to mammography, but I personally know 7 women (excluding my patients)diagnosed with breast cancer in the last 2 years, all with no family history and all under 50. I’ve read the single most common cause of death is breast cancer in women 35-50, so I can’t understand why we don’t want women to routinely check their breasts, we don’t want doctors to routinely examine women’s breasts and we don’t want women to get routine mammograms from age 40-49 and yearly after that.

    I have to say, my biggest surprise was that radiation dose took a back seat to discomfort and anxiety over being called back for more images as a harm to mammography screening.

    • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

      “significantly improves survival”

      Ever heard of lead-time bias? Overdiagnosis bias? The only meaningful numbers are mortality of screened vs unscreened population, not survival. I guess this is one reason “breast specialists” weren’t on the panel – they don’t understand epidemiology which is what is required to evaluate data, not the ability to read mammograms.

      “They created non-peer reviewed data from decades old studies using a
      computer model (with the lowest estimate of reduced mortality from
      mammography of 15% used compared to a high of 54%)”

      Show a single controlled study that has this high mortality reduction number especially for the 40-something women. As to decade-old studies — there haven’t been any new ones.

      “Not one breast specialist was on the panel.”
      It’s not the job description of breast specialists to evaluate data.

      “I personally know 7 women (excluding my patients)diagnosed with breast
      cancer in the last 2 years, all with no family history and all under 50″
      Plural of anecdotes isn’t data. Can you prove that mammography helped in their cases, not just detected a cancer early? Can you prove that none of these cases are overdiagnosis?

    • Anonymous

      Darlyn, Thank you for calling out the way USPSTF is failing the American woman!  After making strides in the area of breast cancer and saving innumerable lives, we are asked to go back to health care guidelines that were abandoned many years ago.  In addition to changes in screening for breast cancer, the new guidelines for pap smears have also been changed.  The reason given for this is that cervical cancer is a “slow grower” and, therefore, there is plenty of time to detect it at a later visit.  What happened to “early detection, early cure”?  I am very frustrated with the present mind set.

      • http://profiles.yahoo.com/u/66NCFAXDWYB7JVNVNLNIUTCUVU Violetta V

        “early detection, early cure” isn’t all it cracked up to be. Not all cancers are the same. Some are not growing and will never spread in your lifetime if remained undetected. Some are aggressive and will kill you anyway. Some are so slow growing that they still haven’t spread when they detected later. The earlier you “detect” something the more chances for it to be “overdiagnosis” – a leision that looks like cancer under the microscope but would never have caused you harm if remained undetected, but if found you’ll be treated and cause side effects from treatment, maybe for life. You may even die from treatment.Screening only helps for a subset of cancers – those that grow slow enough that screening can catch them before they spread yet fast enough that they are destined to spread between the time they are detected by screening and time they are detected by other means e.g. when you notice the tumor. This is what studies are for – to determine if screening can even help.

        “saving innumerable lives” — yes some lives were saved but not nearly as many as you think. But some lives were ruined by overdiagnosis.

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