Transcript Understanding How the U.S. Preventive Services Task Force

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The U.S. Preventive Services Task Force:
The Challenge of Transparency
Dr. Albert Siu
New York Academy of Medicine
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Background
The U.S. Preventive Services Task Force…
• Established in 1984
• Makes recommendations on clinical preventive services for primary care
• The USPSTF scope for clinical preventive services includes:
• screening tests
• counseling services
• preventive medications
• Services offered in a primary care setting or referable from primary care
• Applicable to adults & children with no signs or symptoms
• Recommendations based on a rigorous analysis of peer-reviewed evidence
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Who is the USPSTF?
• Experts in primary care, prevention, research methods
• Congressionally mandated and government supported, by AHRQ,
but independent
• Represent family medicine, internal medicine, pediatrics,
obstetrics/gynecology, nursing, behavioral medicine
• Scientific support from Evidence-based Practice Centers (EPCs)
• Non-member liaisons (“Partners”) from primary care clinician
associations, Federal agencies
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Topic Selection & Prioritization
• Anyone can nominate a topic for the USPSTF to consider via its Web site
• Nominated topics are prioritized to balance the overall portfolio of
recommendations by populations, types of services (screening, counseling,
preventive medications), and disease types
• Scope (i.e., asymptomatic population, primary care setting)
• Health burden
• Expected effectiveness of the preventive service to reduce that burden
• Potential for a Task Force recommendation to affect clinical practice
(based on existing controversy or the belief that a gap exists between
evidence and practice)
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Steps the USPSTF Takes to Solicit Public Input
and Make a Recommendation
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Steps the USPSTF Takes to Solicit Public Input
and Make a Recommendation: Step 1
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Analytic Framework for Lung Cancer Screening
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Analytic Framework for Hepatitis C Screening
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Steps the USPSTF Takes to Solicit Public Input
and Make a Recommendation: Step 2
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Evidence Review:
Define & Retrieve Relevant Evidence
• For each Key Question developed from Analytic Framework:
• Create inclusion/exclusion criteria based on the key questions
defined from the analytic framework
• PubMed, Cochrane, and Other database search (CINAHL, etc.)
• References from key articles, editorials, review articles
• Expert consultation (others, TF members)
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Steps the USPSTF Takes to Solicit Public Input
and Make a Recommendation: Step 3
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Synthesize & Judge Overall Strength of Evidence
• Convincing: Well-designed, well-conducted studies in representative
populations that directly assess effects on health outcomes
• Adequate: Sufficient to determine effects on health outcomes, but
limited by number, quality, or consistency of studies, generalizability
to routine practice, or indirect nature of the evidence
• Inadequate: Insufficient due to limited number or power of studies,
important flaws in their design or conduct, gaps in the chain of
evidence, or lack of information on important health outcomes
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Assessment of Net Benefit & Recommendation
• Likelihood that the assessment of the net benefit of a preventive
service is correct
• Net benefit is defined as benefit minus harm of the preventive service
as implemented in a primary care population
• The USPSTF assigns a certainty level based on the nature of the
overall evidence available to assess the net benefit of a preventive
service
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Level of Certainty
• High Certainty: The available evidence usually includes consistent results
from well-designed, well-conducted studies in representative primary care
populations, using health outcomes. This conclusion is therefore unlikely
to be strongly affected by the results of future studies.
• Moderate Certainty: The available evidence is sufficient to determine the
effects of the preventive service on health outcomes, but confidence in
the estimate is constrained by limitations in the research. As more
information becomes available, the magnitude or direction of the
observed effect could change, and this change may be large enough to
alter the conclusion.
• Low Certainty: The available evidence is insufficient to assess effects on
health outcomes.
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Grade Recommendations
Certainty
of Net
Benefit
Magnitude of Net Benefit
Substantial Moderate Small Zero/negative
High
A
B
C
D
Moderate
B
B
C
D
Low
Insufficient (I Statement)
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Patient Protection and Affordable Care Act:
Investment in prevention…
• A group health plan and a health insurance issuer offering
group or individual health insurance coverage shall provide
coverage for and shall not impose any cost sharing
requirements for
• Evidence-based items or services that have … a rating of ‘A’ or
‘B’ in the current recommendations of the United States Preventive
Services Task Force
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Steps the USPSTF Takes to Solicit Public Input
and Make a Recommendation: Step 4
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Opportunities for Public Input Engagement
Opportunity for
Public Comment
Topic Nomination
Topic Selection
Draft Research Plan Development
Opportunity for
Public Comment
External Review of Draft Research Plan
Approval of External-reviewed Final Research Plan
Draft Evidence Report
External Review of Draft Evidence Report by Experts
USPSTF Topic Workgroup Reviews Evidence &
Prepares Preliminary Recommendation
Full USPSTF Reviews Evidence & Debates Preliminary Recommendation
Topic Workgroup Prepares Full Draft Recommendation Statement
Final Evidence Report & Manuscript Published
External Review of Draft Recommendation Statement
Opportunity for
Public Comment
Consideration of Public Comment & Revision of
Draft Recommendation Statement —
Ratification of Final Recommendation Statement
Publication of Final Recommendation Statement
FUTURE
Opportunity for
Public Comment
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Important Considerations for Success
• The commitment to evidence is what makes the USPSTF
recommendations the “gold standard” for clinical preventive
services
• Recommendations are used for national performance measures and
policy
• Public-private partnership is valuable model
• The USPSTF is an INDEPENDENT entity, but our work is made possible
through the partnership with AHRQ
• AHRQ convenes the USPSTF and provides scientific, technical,
administrative, and dissemination support
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Important Considerations for Success
• Rigorous, systematic and TRANSPARENT processes
• USPSTF Procedure Manual is available online
• Explicit conflict of interest procedures
• Analytic frameworks, draft reports, and draft recommendation
statements are available for public comment
• Expanded dissemination (plain language fact sheets)
• Efforts to engage the media
• Engaging stakeholders in the process through briefings and
other activities
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Public Input on Hepatitis C Screening – 11/28/12
• “Advocates for wider screening for hepatitis C criticized a
government panel Tuesday for not issuing a stronger
recommendation that all baby boomers get a test to make sure
they aren’t infected with the deadly virus. The National Viral
Hepatitis Roundtable, a coalition of groups that battle viral
hepatitis, said that the task force recommendation doesn’t match
up with Centers for Disease Control guidelines that everyone born
between 1945 and 1965 be tested. “We’ll miss a tremendous
opportunity to save lives,” said the executive director of the group.”
• “I'd still argue that the magnitude of benefit is less than either the
CDC or Task Force say it is... there's no direct evidence that
screening for hepatitis C saves lives. New treatments are more
likely to lead to SVR, but there's no evidence that they save lives.”
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Benefits and “Harms” of Public Engagement
• Benefits
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•
•
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Corrections to analytic framework
Improved wording of recommendation statement
Changed recommendation grade based on new evidence
Better articulated critical evidence gaps
• “Harms”
• Longer timeline
• Additional resources
• More time from task force “volunteers” in activities outside of comfort
zone
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Thank you for your interest
www.USPreventiveServicesTaskForce.org
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