2/23/2017 US Preventive Services Task Force and guidelines addressing the needs of Disclosure: underserved communities I have been a member of the US Preventive Services Task Force since 2010 and I am the Kirsten Bibbins-Domingo, PhD, MD, MAS Chairperson, USPSTF current Chair of the USPSTF. Lee Goldman, MD Endowed Chair in Medicine Professor of Medicine and of Epidemiology & Biostatistics University of California, San Francisco 3 4 Outline • Review the procedures of the US Preventive Services Task Force. • Understand the importance and challenge in making recommendations tailored to needs of diverse and underserved communities. • Explore our current approaches in the context several recent recommendation. 1
2/23/2017 5 6 Steps the USPSTF Takes to Solicit Input & make a The U.S. Preventive Services Task Force Recommendation (USPSTF) Topic Nomination • Independent panel of volunteer, non-federal experts (N=16) • Makes recommendations on clinical preventive services offered in the primary care setting • Screening tests • Preventive medications, • Counseling • Recommendations apply to asymptomatic patients – without signs of symptoms of disease. At each stage – 1) Solicit feedback from content experts, sub-specialists 2) Draft posted for public comment 3) Peer-review of evidence report prior to public posting 7 8 Basic USPSTF Methods for Developing Basic USPSTF Methods for Developing Recommendations Recommendations: The Letter Grades Assess the evidence across the analytic framework for: Certainty of Magnitude of Net Benefit Net Benefit • The certainty of the estimates of the potential Substantial Moderate Small Zero/Negative benefits and harms High A B C D • The magnitude of the potential benefits and harms Moderate B B C D Low I • The balance of the benefits and harms, or the magnitude of the net benefit of the preventive service 2
2/23/2017 9 10 USPSTF Grades USPSTF Grades and the Affordable Care Act • A • Private insurers “…shall provide coverage for and shall not All three grades are recommendations in favor of screening • B impose any cost sharing requirements for evidence-based items or They differ by the level of certainty of the evidence and the services that have in effect a rating of ‘A’ or ‘B’ in the current • C magnitude of potential net benefit recommendations of the USPSTF” • D • The law also states “…nothing in this subsection shall be No net benefit and recommend against screening construed to prohibit a plan or issuer from providing coverage for Not enough evidence to make a recommendation services in addition to those recommended by USPSTF or to deny • I coverage for services that are not recommended by the Task Force” NOT a recommendation against screening – rather it’s a call for more research 11 12 USPSTF Grades and the Affordable Care Act • The ACA expands access to evidence-based preventive services, but is the “floor” and not the “ceiling” for coverage • USPSTF evaluates science, but does not determine coverage - Working to make that role is left to insurers, regulators, and lawmakers recommendations useful to all communities in the US • As physicians, we value access for our patients, but as a Task Force, we cannot reinterpret the science to arrive at an A or B recommendation 3
2/23/2017 13 14 Why? The tension • Equity • How much more incremental evidence do we need to • Assuring the health of all Americans make a different recommendation for a particular group? • Health and Healthcare disparities • How do we balance the important goal of calling for more • Addressing communities disproportionately affected by disease research in under-studied groups, with the desire for a specific recommendation for a particular group? • Variation • High quality care • How do we communicate this complexity in a way that is • Limit unnecessary variation, useful for patients and clinicians? • Pay attention to necessary variation Considering diverse communities at each 15 16 step Topic Nomination 1. Communicating “Who is at risk?” • Engaging stakeholder groups to provide comments at each step • Continuing to advance methodologies regarding heterogeneity in the evidence review • Enhanced communication in our final products 4
2/23/2017 17 18 Providing more detail on who to screen for syphilis The USPSTF recommends screening for syphilis in persons who are at increased risk for infection. Based on 2014 surveillance data, men who have sex with men (MSM) and men and women living with HIV have the highest risk for syphilis infection; 61.1% of cases of primary and secondary syphilis occurred among MSM, and approximately one-half of all MSM diagnosed with syphilis were also coinfected with HIV. One study found that rates of syphilis coinfection were 5 times higher in MSM living with HIV compared with men living with HIV who do not have sex with men. 4 Based on older study data from northern California, the adjusted relative risk for syphilis infection in persons living with HIV (vs those without HIV) was 86.0 (95% CI, 78.6 to 94.1); 97% of those living with HIV and with incident syphilis were male. 5 When deciding which other persons to screen for syphilis, clinicians should be aware of the prevalence of infection in the communities they serve, as well as other sociodemographic factors that may be associated with increased risk of syphilis infection . Factors associated with increased prevalence that clinicians should consider include history of incarceration, history of commercial sex work, certain racial/ethnic groups, and being a male younger than 29 years, as well as regional variations that are well described. Men accounted for 90.8% of all cases of primary and secondary syphilis in 2014. Men aged 20 to 29 years had the highest prevalence rate, nearly 3 times higher than that in the average US male population. 1 Syphilis prevalence rates are also higher in certain racial/ethnic groups (among both men and women); in 2014, prevalence rates of primary and secondary syphilis were 18.9 cases per 100,000 black individuals, 7.6 cases per 100,000 Hispanic individuals, 7.6 cases per 100,000 American Indian/Alaska Native individuals, 6.5 cases per 100,000 Native Hawaiian/Pacific Islander individuals, 3.5 cases per 100,000 white individuals, and 2.8 cases per 100,000 Asian individuals. 1 The southern United States comprises the largest proportion of syphilis cases (41%); however, the case rate is currently highest in the western United States (7.9 cases per 100,000 persons). Metropolitan areas in general have increased prevalence rates of syphilis. 1 Risk factors for syphilis often do not present independently and may frequently overlap. In addition, local prevalence rates may change over time, so clinicians should be aware of the latest data and trends for their specific population and geographic area. 19 20 Abnormal blood glucose and Type 2 diabetes: Screening 2. Balancing the call for more research, with providing clinicians useful information for their practice 5
2/23/2017 21 22 Abnormal blood glucose and Type 2 diabetes: What appears on our website Screening 23 24 3. Important disparities may not necessarily be alleviated by increased screening 6
2/23/2017 25 26 The interests in clinical prevention are many, significant, and complex. 27 28 Impact of Race on Effectiveness of Mammography Screening • African American women are more likely to die of breast cancer than white women (31 v. 22 deaths per 100,000 women per year) • Reason for the disparity not entirely clear: • Biology : African American women more likely to develop triple-negative phenotypes and other aggressive tumors • Socioeconomic : Associations between being African American and experiencing delays in receipt of health care services for cancer (even lack of treatment altogether) • African American women severely underrepresented in the RCTs of screening (largely performed in Europe in white women) • Direct evidence is lacking for this population and this represents a critical research need 7
2/23/2017 29 30 4. But some disparities will absolutely be addressed by increased screening 31 32 5. The call for more research is important 8
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