Following the release of the U.S. Preventive Services Task Force's (Task Force/USPSTF) new breast cancer screening recommendations for women, the media and special interest groups, particularly those strongly opposed to any healthcare reform proposal, were quite vocal about the new recommendations. These groups misconstrued the recommendations of the Task Force, equating them to government rationing of healthcare services, suggesting a link between the independent work of the Task Force and the legislative processes of Congress. Unfortunately, the timing of the new recommendations coincided with the heated debate in Congress on healthcare reform, thrusting the issue into the limelight.
The USPSTF clearly states that the recommendations were proposed independent of the U.S. government and do not represent the Agency for Healthcare and Research Quality or the U.S. Department of Health and Human Services' official position. The purpose of the USPSTF is to "evaluate the quality and strength of the evidence, the net health benefit (benefit versus harms) associated with services, and the level of certainty this benefit will be realized if these services are provided in primary care."1
About the USPSTF
The 16-member USPSTF panel includes experts in prevention, evidence-based medicine, and primary care. There are 13 MDs (eight also have master's degrees in public health) and one PhD in public health. The remaining two members are nurses, Drs. Lucy Marion and Bernadette Melnyk, both highly respected within and outside nursing circles. In addition, the American Academy of Nurse Practitioners and the National Association of Pediatric Nurse Practitioners, representing thousands of NPs and other advanced practice nurses, are two of the primary care partners. Partner organizations provide peer review of drafts and can assist with dissemination of the guidelines.Thus, nurses can be assured their voices are heard on the USPSTF's panel.
The letter grading system the USPSTF uses to rate the quality and level of the evidence for a particular recommendation is familiar. With reference to breast cancer screening, the new guidelines2 include: performing biennial screening mammography for women ages 50 to 74 (B); before age 50 years, consider individual risk and patient values before screening (C); uncertainty in screening mammography for women age 75 or older (I); discouraging teaching women breast self-exam (D); uncertainty of benefits and harms of clinical breast exam beyond screening mammography in women age 40 or older (I); and uncertainty of benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as a screening modality (I).
Using guidelines in practice
What do guidelines mean for NPs in primary care? The new USPSTF guidelines are recommendations, not policy. In publishing previous commentaries on particular USPSTF guidelines, a clinician must not only appraise the evidence provided in the guideline but also search for other evidence relative to a particular patient population or special considerations for individual patients. Providing evidence-based care suggests informed responsibility. Constraints on providing appropriate care become irresponsible when driven by other interests. The fear and reality are that insurers usually adopt such recommendations as the rule in determining what services will be a covered (paid) benefits for enrolled members.
As an NP, stay informed and appraise the evidence. Evaluate your practice and impact on patient outcomes. Inform the uninformed and communicate with your legislators. Keep your patients actively involved in the loop. Prevention is a thousand times healthier than cure.
Jamesetta Newland, PhD, RN, FNP-BC, FAANP, FNAP
Editor-in-Chief [email protected]
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