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Dont Listen To What They Say. Watch What They Do.

Posted Dec 17 2009 2:10pm

Stanley Feld M.D., FACP,MACE

If President Obama’s healthcare bill is passed there is certain to be an increase in taxes, an increase in the budget deficit and a rationing of healthcare.

The President promised an increase in funding for preventative medicine. The term preventative medicine should mean discovering a disease process before it manifests itself through its complications. After discovering the disease it should be treated in the best possible way available.

The federal government is going to spent billions of dollars expanding a bureaucracy to further evaluate best practices.. The Agency for Healthcare Research and Quality was created to standardize the practice of medicine. The organization encouraged medical specialty organizations to write guidelines for the care of diseases in their specialty. A National Clearing House was created that published these guidelines. These guidelines are to be updated every five years.

I was suspicious of the intent of the AHRQ. Medical knowledge changes at about 10% per year. I believe that physicians in a specialty area have an obligation to physicians in all specialties to help them keep current. Guidelines are usually devoid of clinical judgment.

I was afraid the AHRQ would use guidelines as a weapon to punish physicians who were not current.

I was chair of the AACE guidelines for the treatment of Type 2 Diabetes Mellitus. I was also the co chair for AACE’s guidelines for hyper and hypothyroidism, thyroid nodules and thyroid cancer.

My goal was to help primary care physicians understand the Clinical Endocrinologists’ interpretation of the state of the art diagnosis and treatment of endocrine diseases. AACE had no ulterior motive. I hoped the AHRQ had no ulterior motives.

The U.S. Preventive Services Task Force is a branch of the Agency for Healthcare Research and Quality. USPTF started writing its own guidelines for diagnosis and treatment of many diseases. The USPTF does not seek input from subspecialty groups. The panel selects major articles on diseases from the literature and grades these articles. From the grading of the selected articles it develops guidelines on the use of procedures and treatments.

There are several problems with this method of developing guidelines. There is a danger that the best articles are not selected by non experts in that disease. There is also a danger that the natural history of the disease is overlooked. The natural history of many diseases is not considered in many “major” articles.

A vivid example of this is in the Women’s Health Initiative.

The most important defect in the USHPTF guidelines is it disregards the most important element of medical care, namely physicians’ clinical judgment.

The USPFS guidelines disregard clinical judgment and the patient physician relationship. In fact they destroy these critical elements in the therapeutic relationship between physician and patient.

USPHTF guidelines have rationed access to care for several years. President Obama is extending the USPHTF’s scope in rationing healthcare.

“Think Congress is regretting having allocated over a billion dollars to let the government generate studies to tell us what medical tests and procedures should be covered under Obamacare?”

I am most familiar with the US Preventive Services Task Force’s guidelines for the diagnosis and treatment of osteoporosis. I did not recognize one expert in the task force’s panel to evaluate the evidence for the diagnosis and treatment of osteoporosis.

The panel might be experts in evaluating the statistical power of the clinical studies chosen. However if clinical studies were not done to evaluate diagnosis and treatment of males with osteoporosis the USPHF conclusion would be there is no evidence for this diagnosis and treatment. The government would not approve bone density studies for elderly men even though there is an abundance of clinical evidence that hip fractures are as common in men as they are in women.

Most large clinical studies are funded by the pharmaceutical industry. Most of the osteoporosis studies have been done on women. Therefore there are no large studies in males. There it is easy to arrive at the conclusion that there is no evidence for diagnosing and treating males. The government will not pay for the evaluation and treatment of males for osteoporosis.

Experts in osteoporosis who understand the natural history of osteoporosis would disagree. The panel of U.S. Preventative Task Force did not ask osteoporosis experts for an opinion about the guidelines and disregarded the guidelines written by experts in the area.

Similar defects occurred with the USPTF’s recommendations for breast cancer. The breast cancer recommendations reviewed only 10 studies. The reviewers admit their conclusions cannot be generalized to individual forms of breast cancer and different groups of patients.

No sooner had the Health and Human Services Department's U.S. Preventative Services Task Force recommended against mammography for women under 50 than Secretary Kathleen Sebelius rushed to say don't worry. The decision had "caused a great deal of confusion and worry among women," she said, promising that no policies would change.”

Secretary Kathleen Sebelius said no policy would change today. It will change in the near future. The bankrupt State of California already has changed its policy.

“Although women ages 50 and older will still be eligible, women ages 40-49 will no longer be screened.”

I will have more to say about the USPHTF and its Breast Screening Guidelines in the future.

In the meantime watch what they do. Don’t listen to what they say.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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