Project description:Recently, health screening recommendations have gone beyond screening for early-stage, asymptomatic disease to include "screening" for presently experienced health problems and symptoms using self-report questionnaires. We examined recommendations from three major national guideline organizations to determine the consistency of recommendations, identify sources of divergent recommendations, and determine if guideline organizations have identified any direct randomized controlled trial (RCT) evidence for the effectiveness of questionnaire-based screening.We reviewed recommendation statements listed by the Canadian Task Force on Preventive Health Care (CTFPHC), the United Kingdom National Screening Committee (UKNSC), and the United States Preventive Services Task Force (USPSTF) as of 5 September 2016. Eligible recommendations focused on using self-report questionnaires to identify patients with presently experienced health problems or symptoms. Within each recommendation and accompanying evidence review we identified screening RCTs.We identified 22 separate recommendations on questionnaire-based screening, including three CTFPHC recommendations against screening, eight UKNSC recommendations against screening, four USPSTF recommendations in favor of screening (alcohol misuse, adolescent depression, adult depression, intimate partner violence), and seven USPSTF recommendations that did not recommend for or against screening. In the four cases where the USPSTF recommended screening, either the CTFPHC, the UKNSC, or both recommended against. When recommendations diverged, the USPSTF expressed confidence in benefits based on indirect evidence, evaluated potential harms as minimal, and did not consider cost or resource use. CTFPHC and UKNSC recommendations against screening, on the other hand, focused on the lack of direct evidence of benefit and raised concerns about harms to patients and resource use. Of six RCTs that directly evaluated screening interventions, five did not report any statistically significant primary or secondary health outcomes in favor of screening, and one trial reported equivocal results.Only the USPSTF has made any recommendations for screening with questionnaires for presently experienced problems or symptoms. The CTFPHC and UKNSC recommended against screening in all of their recommendations. Differences in recommendations appear to reflect differences in willingness to assume benefit from indirect evidence and different approaches to assessing possible harms and resource consumption. There were no examples in any recommendations of RCTs with direct evidence of improved health outcomes.

Project description:ImportanceThe US Preventive Services Task Force (USPSTF) is updating its 2016 colorectal cancer screening recommendations.ObjectiveTo provide updated model-based estimates of the benefits, burden, and harms of colorectal cancer screening strategies and to identify strategies that may provide an efficient balance of life-years gained (LYG) from screening and colonoscopy burden to inform the USPSTF.Design, setting, and participantsComparative modeling study using 3 microsimulation models of colorectal cancer screening in a hypothetical cohort of 40-year-old US individuals at average risk of colorectal cancer.ExposuresScreening from ages 45, 50, or 55 years to ages 70, 75, 80, or 85 years with fecal immunochemical testing (FIT), multitarget stool DNA testing, flexible sigmoidoscopy alone or with FIT, computed tomography colonography, or colonoscopy. All persons with an abnormal noncolonoscopy screening test result were assumed to undergo follow-up colonoscopy. Screening intervals varied by test. Full adherence with all procedures was assumed.Main outcome and measuresEstimated LYG relative to no screening (benefit), lifetime number of colonoscopies (burden), number of complications from screening (harms), and balance of incremental burden and benefit (efficiency ratios). Efficient strategies were those estimated to require fewer additional colonoscopies per additional LYG relative to other strategies.ResultsEstimated LYG from screening strategies ranged from 171 to 381 per 1000 40-year-olds. Lifetime colonoscopy burden ranged from 624 to 6817 per 1000 individuals, and screening complications ranged from 5 to 22 per 1000 individuals. Among the 49 strategies that were efficient options with all 3 models, 41 specified screening beginning at age 45. No single age to end screening was predominant among the efficient strategies, although the additional LYG from continuing screening after age 75 were generally small. With the exception of a 5-year interval for computed tomography colonography, no screening interval predominated among the efficient strategies for each modality. Among the strategies highlighted in the 2016 USPSTF recommendation, lowering the age to begin screening from 50 to 45 years was estimated to result in 22 to 27 additional LYG, 161 to 784 additional colonoscopies, and 0.1 to 2 additional complications per 1000 persons (ranges are across screening strategies, based on mean estimates across models). Assuming full adherence, screening outcomes and efficient strategies were similar by sex and race and across 3 scenarios for population risk of colorectal cancer.Conclusions and relevanceThis microsimulation modeling analysis suggests that screening for colorectal cancer with stool tests, endoscopic tests, or computed tomography colonography starting at age 45 years provides an efficient balance of colonoscopy burden and life-years gained.

Project description:BACKGROUND:US Preventive Services Task Force (USPSTF) released new recommendations on statin use for atherosclerotic cardiovascular disease (ASCVD) prevention. The Affordable Care Act (ACA) mandates USPSTF recommendations with an "A" or "B" grade receive insurance coverage without copayment. We assessed the potential impact of these recommendations. OBJECTIVE:To assess the US population meeting criteria for statin use and factors associated with use, and calculate associated costs. DESIGN AND MEASURES:We estimated 10-year ASCVD event risk scores from National Health and Nutrition Examination Survey data using Pooled Cohort Equations from the American College of Cardiology/American Heart Association and applied them to Medical Expenditure Panel Survey data. We estimated the population meeting USPSTF criteria and calculated the number of statin prescription fills and out-of-pocket and total costs. We assessed associations between statin use and sociodemographic and health characteristics and national trends in use from 1996 to 2014. PARTICIPANTS:A nationally representative sample of people aged ??40 years, representing 150 million people living in the USA. KEY RESULTS:Of 26.8 million adults recommended for statins, only 41.8% were taking them. Female sex, Hispanic ethnicity, uninsured status, or living in the South was associated with lower odds of using statins. Under ACA, people with private insurance would avoid out-of-pocket cost of $9 for each generic prescription, resulting in savings of approximately $44 in annual costs. ACA's mandate for insurance coverage would result in a $193 million shift in out-of-pocket cost for statins from patients to private insurers. CONCLUSIONS:New USPSTF recommendations may result in decreased out-of-pocket costs and expanded access to statins. Previous research has shown that eliminating copayments increased adherence and decreased rates of ASCVD events without increasing overall healthcare costs. Future research will determine whether the USPSTF's recommendations will result in similar findings.

Dataset Information

Screening for type 2 diabetes mellitus to prevent vascular complications: updated recommendations from the Canadian Task Force on Preventive Health Care.

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