The USPSTF anxiety recommendations do not address people with intellectually disability -- A New JAMA viewpoint shows how ridiculous academics are becoming
I was reading JAMA when I came across a catchy, faddish headline
What can USPSTF do about this? I thought to myself, and eagerly read the article.
Suffice it to say, it was ridiculous. Let’s take a look at some quotes.
First, I have to give you the whole passage before I summarize it b/c you will think I made it up.
Wait? The USPSTF recommended anxiety screening for the general population with NO RANDOMIZED data that such screening improves outcomes. Instead, they relied on a series of linked questions, which are a lower form of evidence, and beneath the historical USPSTF standard. We would never use such linked questions for other screening modalities. Even PSA has randomized studies.
Despite this low level evidence, USPSTF gave a loft (B) recommendation, which obliges payers to cover it, per the ACA. Now the authors of the current JAMA Viewpoint notice that if you have an intellectual disability, you might not be able to fill out the questionairre.
Ok, that is why you have a doctor. A doctor’s job is to tailor care to each individual. If a doctor is taking care of someone with an intellectual disability and they seem anxious— that doctor should address that.
But here the authors want USPSTF to address that at a SCREENING level— meaning that presumably the doctor did not think anything was wrong. And the USPSTF ‘failed to comment’ about what do to then.
Of course they didn’t comment! What are they supposed to say? We don’t have good data to screen everyone, so of course we don’t have any data for people with intellectual disabilities.
What do the authors want? USPSTF should just make shit up?
Merely because anxiety is higher in this group, does not mean screening is beneficial. If anything more anxiety cases may be detected in routine practice, so screening might have less yield. Also: Is screening anyone for anxiety a good thing?
No one has any idea. Least of all, the USPSTF.
USPSTF already made a mistake to debut anxiety screening without a randomized trial testing whether screening improves outcomes. Commenting on a subpopulation (people with intellectually disability) would take them further away from an already weak evidence base.
At some point we have to admit we fail people by not running randomized studies. We have failed the general population, and of course we failed people with intellectual disabilities.
Put another way: USPSTF is barely able to make recommendations for average risk people. They don’t have specific guidance for women with Li Fraumeni or other cancer syndromes, now you want them to issue guidance for doctors taking care of people with intellectual disabilities who might be anxious?
Here is another argument from the paper
What? Of course, anyone who isn’t an idiot will know that you can’t ask someone in a wheelchair to climb up on the high table. Why does USPSTF need to comment on this?
Also if someone’s mobility is really impaired & they have other issues (e.g older, frail, sick person in wheelchair) perhaps you should stop doing the mammogram althogether! In fact, mammography is itself a low value service, as I explain here, too often done for people with limited life expectancy. (That’s the real problem!)
I don’t understand this viewpoint other than it uses buzzwords.
Common sense always applies in medicine, but apparently not in the peer reviewed literature.