Talk More, Test Less, Panel Urges Health Providers
Talk More, Test Less, Panel Urges Health Providers
A task force of preventive health specialists recently recom its, significantly change the use of some screening tests, and ensure that several newer immunizations are routinely provided.
The US Preventive Services Task Force, an independent panel first convened in 1984 as an initiative of the US Public Health Service, issued the first revision of its 1989 guide to disease prevention and health promotion, based on a review of scientific evidence.
Many of the recommended changes in the 1995 "Guide to Clinical Preventive Services, 2nd Edition" reflect new evidence about important health benefits of selected preventive services, according to the panel. Other changes reflect a more critical look at the balance of harms and benefits of screening tests now in wide use. The report also reaffirms many of the disease- and injury-prevention practices recommended in 1989.
In accepting the report from the task force, Philip R. Lee, MD, assistant secretary for health, noted that "effective disease and injury prevention is our most efficient tool for improving our health status as individuals and as a nation. This report, like its predecessor, moves us further toward prevention that works."
Targeting the Periodic Health Exam
The 10-member task force rejected the traditional emphasis on a standardized annual physical examination as an effective tool for improving the health of patients. Instead, they emphasized that the content and frequency of the periodic health examination need to be tailored to the age, health risks, and preferences of each patient.
The panel recognized the proven benefits of specific measures, such as periodic screening for high blood pressure and cervical cancer, scheduled vaccinations, and counseling about tobacco, alcohol, and other lifestyle issues. In contrast, the task force found little evidence of important benefits from other tests often included in routine check-ups, such as blood tests for diabetes, thyroid diseases, or anemia; chest x-rays; ECGs; and urine tests.
"Our review affirms the effectiveness of a variety of preventive interventions, many of which are underutilized in routine practice. At the same time, other widely used preventive practices, many of which are costly and some of which are even dangerous, show little or no evidence that they improve health," said Harold C. Sox, Jr, MD, task force chair. "We based our recommendations on the scientific evidence. All too often, the evidence was too weak for us to make a strong recommendation. We need to strengthen the evidence on which our prevention practices rest," added Dr. Sox, who is chair of medicine at Dartmouth-Hitchcock Medical Center.
Although none of the recommendations depended on cost, the task force noted the considerable cost of the widespread use of many unproven tests and procedures, such as routine ECGs in healthy adults and ultrasound scans in low-risk pregnancies.
The task force included specialists in family medicine, internal medicine, obstetrics and gynecology, pediatrics, and preventive medicine. Over 30 outside experts in medicine, nursing, public health, epidemiology, and health promotion and education also contributed to the project.
The panel assessed more than 6,000 studies of over 200 different interventions for more than 70 diseases and conditions. These included 53 screening tests (for cardiovascular disease, cancer, metabolic and nutritional diseases, infectious diseases, vision and hearing disorders, prenatal disorders, congenital disorders, musculoskeletal disorders, mental disorders and substance abuse); 11 counseling topics ranging from promoting seat belt use to preventing tobacco use; immunization against 12 common childhood and adult diseases; and the use of aspirin and postmenopausal hormones to prevent disease.
The task force has been a pioneer in rigorously evaluating scientific evidence to decide the merits of prevention measures. Since the publication of the 1989 report, the evidence-based method has become the standard for developing guidelines for medical and nursing practice. Based on this method, the task force recommends only those preventive services with demonstrated effectiveness in preventing disease, disability, or death.
Broad Conclusions About Effective Preventive Care
The report draws several broad conclusions about effective preventive care:
- Counseling patients about personal health practices (smoking, diet, physical activity, drinking, injury prevention, and sexual practices) remains one of the most underused, but important, parts of the health visit.
- Preventive services offered by the clinician should be tailored to the specific behaviors and risk factors of individual patients, not offered as a standard "routine check-up" given to all patients.
- Patients should share in decisions about preventive services. Their personal preferences are important in determining an approach to prevention that is optimal for them as individuals. This is especially true when the evidence of benefit is weak.
- Doctors and nurses should try to deliver prevention messages and services during every encounter with their patients, especially for high-risk patients who are often the least likely to see clinicians for routine check-ups.
Value of Specific Preventive Strategies Endorsed or Rejected
The new or revised recommendations support:
- Flexible sigmoidoscopy and/or annual fecal occult blood testing to screen for colorectal cancer
- Targeting routine screening for high cholesterol and other lipid disorders to men 35 to 65 years old, women ages 45 to 65, and others at increased risk for heart disease
- Daily multivitamins with folic acid for all women who can become pregnant (to prevent neural tube defects)
- Routine vaccination of all newborns, children, adolescents, and young adults against hepatitis B
- Routine vaccination of children against chickenpox
- Counseling parents of young children on measures to reduce the risk of household and recreational injuries
- Discussion of the use of estrogen therapy with all postmenopausal women
On the other hand, the panel came out against:
- Routine screening for prostate cancer with prostate-specific antigen (PSA) or digital rectal examination
- Routine urine tests for early detection of bladder cancer or asymptomatic urinary tract infection
To order a printed copy of the "Guide to Clinical Preventive Services, 2nd Edition, " contact the superintendent of Documents, US Govenment Printing Office, at 202-512-1800. The stock number of the publication is 017-001-00525-8 and the single copy price is $35 (shipping included).
Internet access to the guide will be available in early 1966 via the National Library of Medicine' HSTAT (Health Services/Technology Assessment Text) database at http:// text.nim.nih.gov/ and the Office of Disease Prevention and Health Promotion at http://odphp.oash.dhhs.gov/.