Is the US ready for evidence based care?

One day a few weeks ago, I awoke to a story on our local public radio station about the new guidance that had been issued on mammography screening by the US Preventive Services Task Force.  For those not in the know, this is an independent body whose mission is to consider “rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counselling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services”.

The taskforce had recommended changing routine mammography screening for women in the US from the current policy of yearly from the age of 40, to biennially from the age of 50.  This change in recommendation is based on an evaluation of the evidence for mammography screening, including the associated risks of over screening.  From my own particular viewpoint this seemed a sensible change in policy (after all in the UK we currently screen women over 50 every three years), given the evidence on risks and benefits.

However, this is the US, and we are in the middle of the biggest debate about health care reform this country has ever engaged in.  Mammography screening has never been so political.  Enter the Republicans highlighting that this was a prime example of how reforming health care would lead to rationing, government getting in the middle of health care between a woman and her doctor, and numerous anecdotal stories of how “breast screening saved my life”.  The Obama administration moved quickly to distance themselves from the policy advice, suggesting that it was a decision for women and their doctors.  I heard an interview with a bemused representative from the task force who was trying to highlight that the guidance also emphasised the need for individualized decision making about routine screening before the age of 50.

Ironically, even in women where there is no controversy (aged between 50 and 70), the rates of routine mammography screening in the US are around 72% of all eligible women, a figure slightly below the 76% of the UK screening program.  There are a number of reasons why women in the US do not get screening, many of which may well be addressed by the health care reforms currently being debated in the senate.  What was lacking in the current debate was any real consideration of why the guidance might have changed; the problems with ‘over-diagnosis’, false positives and the additional risks that these incur for women.  Admittedly, it is clear that there are disagreements among the experts about what the best approach for screening may be. However, patients and their doctors in the US are not used to thinking about risks as well as benefits; the mantra has always been screening saves lives – so the emphasis is saving lives no matter what the cost. Evidence based care requires you to think about costs and benefits (value based as well as monetary); given the current climate it doesn’t look like the US is ready for it yet.