Letters to the Editor
U.S. Preventive Services Task Force Diabetes Screening To the Editor: In a recent AJPM article, Casagrande and colleagues1 attempt to make a case for altering the diabetes screening recommendation by the U.S. Preventive Services Task Force (USPSTF) based on the current recommendation’s low sensitivity in detecting previously undetected type 2 diabetes and other cardiovascular disease (CVD) risk factors that have a high prevalence in those with undetected diabetes. Although test sensitivity is one criterion to consider in assessing screening tests, it is not the most important. The key criterion is that detecting asymptomatic disease by screening results in better patientoriented outcomes than by waiting for detection by the presentation of symptoms. It matters little if prediabetes or early diabetes is not detected if patient-oriented outcomes are not changed by early detection, especially if screening leads to unnecessary testing, harm from false test results, labeling, and unneeded, overaggressive therapies. The prevalence of CVD risk factors in those with undetected diabetes should not be a consideration because the USPSTF has developed a screening recommendation for each of these risks, when evidence supports that reducing them reduces CVD morbidity or mortality. They will be detected without screening for diabetes if these recommendations are followed. Aroda and Fonseca,2 in an accompanying editorial, make the same mistaken arguments but then imply that the recommendation methodology of the American Diabetes Association (ADA) is superior to that of the USPSTF because it is updated annually. The IOM has documented the lack of scientific rigor in many clinical practice guidelines and has listed key criteria for assessing guideline quality.3 They are:
transparency of the process; conflict of interest policies that prevent conflicted
panel members from influencing the outcome and prevents industry influence on guideline panels; panel composition that includes a range of disciplines and skills and facilitates patient stakeholder input; an independent assessment of the totality of the evidence using standard and robust methodology to assess each study for quality and to rank the overall quality of evidence on each question; arriving at a strength of recommendation based on the evidence and an assessment of harm in addition to benefits; external review; and updating as new, important evidence is available.
& 2014 American Journal of Preventive Medicine
The methodology of the USPSTF was used as a model in the IOM report and is superior to almost every other group, including the ADA, which explains why the Task Force recommendations often differ. Historically when differences have occurred, the USPSTF position has usually been the one that survived the test of time. A robust, conflict-free process every 5 years is superior to a lesser-quality process annually. However, it is time for the Task Force to reassess the evidence on diabetes screening. They are in the process of doing so and it so states on their website. It is not appropriate, however, to attempt to influence the process by citing individual studies without rigorously assessing them for quality (cherry picking) and applying inappropriate criteria for making a decision on screening tests. Let’s wait and see what a robust, independent assessment of the totality of the evidence shows and endorse recommendations that reflect it. Campos-Outcalt, MD, MPA, Chair Department of Family, Community, and Preventive Medicine, University of Arizona College of Medicine, Phoenix AZ E-mail: [email protected] http://dx.doi.org/10.1016/j.amepre.2013.09.003 Dr. Campos-Outcalt is the liaison to the USPSTF representing the American Academy of Family Physicians, and he participates on numerous clinical practice guideline panels representing the AAFP.
References 1. Casagrande SS, Cowie CC, Fradkin JE. Utility of the U.S. Preventive Services Task Force criteria for diabetes screening. Am J Prev Med 2013;45:167–74. 2. Aroda VR, Fonseca VA. U.S. Preventive Services Task Force criteria for diabetes screening. Time to revisit the evidence? Am J Prev Med 2013;45:246–7. 3. IOM. Clinical practice guidelines we can trust. Washington DC: National Academies Press, 2011.
Author Response We hope that our analysis will be helpful to the U.S. Preventive Services Task Force (USPSTF) as it reviews its guidelines. Unfortunately, research specifically studying interventions in people with undiagnosed diabetes is not available. However, as we note in our paper, research does show that HbA1c control early in the course of type 2 diabetes prevents complications.1 In addition, many of those who would not be tested under the USPSTF guidelines have an HbA1c level above the target shown to improve clinical outcomes for individuals when therapy is intensified early in the course of type 2 diabetes.
Published by Elsevier Inc.
Am J Prev Med 2014;46(1):e17–e18
e17
U.S. Preventive Services Task Force Diabetes Screening To the Editor: In a recent AJPM article, Casagrande and colleagues1 attempt to make a case for altering the diabetes screening recommendation by the U.S. Preventive Services Task Force (USPSTF) based on the current recommendation’s low sensitivity in detecting previously undetected type 2 diabetes and other cardiovascular disease (CVD) risk factors that have a high prevalence in those with undetected diabetes. Although test sensitivity is one criterion to consider in assessing screening tests, it is not the most important. The key criterion is that detecting asymptomatic disease by screening results in better patientoriented outcomes than by waiting for detection by the presentation of symptoms. It matters little if prediabetes or early diabetes is not detected if patient-oriented outcomes are not changed by early detection, especially if screening leads to unnecessary testing, harm from false test results, labeling, and unneeded, overaggressive therapies. The prevalence of CVD risk factors in those with undetected diabetes should not be a consideration because the USPSTF has developed a screening recommendation for each of these risks, when evidence supports that reducing them reduces CVD morbidity or mortality. They will be detected without screening for diabetes if these recommendations are followed. Aroda and Fonseca,2 in an accompanying editorial, make the same mistaken arguments but then imply that the recommendation methodology of the American Diabetes Association (ADA) is superior to that of the USPSTF because it is updated annually. The IOM has documented the lack of scientific rigor in many clinical practice guidelines and has listed key criteria for assessing guideline quality.3 They are:
transparency of the process; conflict of interest policies that prevent conflicted
panel members from influencing the outcome and prevents industry influence on guideline panels; panel composition that includes a range of disciplines and skills and facilitates patient stakeholder input; an independent assessment of the totality of the evidence using standard and robust methodology to assess each study for quality and to rank the overall quality of evidence on each question; arriving at a strength of recommendation based on the evidence and an assessment of harm in addition to benefits; external review; and updating as new, important evidence is available.
& 2014 American Journal of Preventive Medicine
The methodology of the USPSTF was used as a model in the IOM report and is superior to almost every other group, including the ADA, which explains why the Task Force recommendations often differ. Historically when differences have occurred, the USPSTF position has usually been the one that survived the test of time. A robust, conflict-free process every 5 years is superior to a lesser-quality process annually. However, it is time for the Task Force to reassess the evidence on diabetes screening. They are in the process of doing so and it so states on their website. It is not appropriate, however, to attempt to influence the process by citing individual studies without rigorously assessing them for quality (cherry picking) and applying inappropriate criteria for making a decision on screening tests. Let’s wait and see what a robust, independent assessment of the totality of the evidence shows and endorse recommendations that reflect it. Campos-Outcalt, MD, MPA, Chair Department of Family, Community, and Preventive Medicine, University of Arizona College of Medicine, Phoenix AZ E-mail: [email protected] http://dx.doi.org/10.1016/j.amepre.2013.09.003 Dr. Campos-Outcalt is the liaison to the USPSTF representing the American Academy of Family Physicians, and he participates on numerous clinical practice guideline panels representing the AAFP.
References 1. Casagrande SS, Cowie CC, Fradkin JE. Utility of the U.S. Preventive Services Task Force criteria for diabetes screening. Am J Prev Med 2013;45:167–74. 2. Aroda VR, Fonseca VA. U.S. Preventive Services Task Force criteria for diabetes screening. Time to revisit the evidence? Am J Prev Med 2013;45:246–7. 3. IOM. Clinical practice guidelines we can trust. Washington DC: National Academies Press, 2011.
Author Response We hope that our analysis will be helpful to the U.S. Preventive Services Task Force (USPSTF) as it reviews its guidelines. Unfortunately, research specifically studying interventions in people with undiagnosed diabetes is not available. However, as we note in our paper, research does show that HbA1c control early in the course of type 2 diabetes prevents complications.1 In addition, many of those who would not be tested under the USPSTF guidelines have an HbA1c level above the target shown to improve clinical outcomes for individuals when therapy is intensified early in the course of type 2 diabetes.
Published by Elsevier Inc.
Am J Prev Med 2014;46(1):e17–e18
e17
