Personalized Estimates of Benefit From Preventive Care Guidelines

Taksler, Glen B.; Keshner, Melanie; Fagerlin, Angela; Hajizadeh, Negin; Braithwaite, R. Scott

doi:10.7326/0003-4819-159-3-201308060-00005

Cited by 49 publications

(59 citation statements)

References 30 publications

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“…Of course, the time available in clinical practice to discuss and provide the numerous preventive care recommendations is inadequate. 75 This makes prioritization and personalization of preventive care all the more essential, allowing more time to be spent on medical care that is most likely to help an older individual achieve his/her goals and is least likely to cause harm.…”

Section: Discussionmentioning

confidence: 99%

Screening Mammography in Older Women

Walter

Schonberg

2014

JAMA

206

231

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Importance Guidelines recommend individualizing screening mammography decisions for women 75 and older. However, little pragmatic guidance is available to inform this approach. Objective To provide an evidence-based approach to individualizing decision-making about screening mammography that considers older women's risk of breast cancer and the potential benefits and harms of screening in the context of varying life expectancies and preferences. Evidence Acquisition We searched PubMed for English-language studies in peer-reviewed journals published from January 1, 1990 to February 1, 2014 to identify risk factors for late-life breast cancer in women 65 and older and to quantify the benefits and harms of screening mammography for women 75 and older. Findings Age is the major risk factor for late-life breast cancer. In general, traditional breast cancer risk factors (e.g., age at first birth, age at menarche) that represent hormonal exposures in the distant past are less predictive of late-life breast cancer than factors indicating recent exposure to endogenous hormones (e.g., bone mass, obesity). None of the randomized trials of screening mammography included women over age 74, such that it is uncertain whether screening mammography is beneficial in these women. Observational data favor extending screening mammography to older women who have a life expectancy > 5-10 years. Modeling studies suggest approximately 2 fewer women per 1,000 die from breast cancer if women in their 70's continue biennial screening for 10 years, versus stopping screening at age 69. Potential benefits must be weighed with potential harms of continued screening over ten years, which include false-positive mammograms (~200 per 1,000 women screened) and overdiagnosis (~13 per 1,000 women screened). Providing these frequencies both verbally and graphically may help inform older women's decision-making. Conclusions and Relevance For women with less than a 5-10 year life expectancy, recommendations to stop screening mammography should be framed around increased harms and the need to refocus health promotion on interventions likely to be beneficial over a shorter timeframe. For women with a life expectancy > 5-10 years, the decision about whether potential benefits of screening outweigh harms is a value judgment that requires a realistic understanding of screening outcomes.

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Section: Discussionmentioning

confidence: 99%

Screening Mammography in Older Women

Walter

Schonberg

2014

JAMA

206

231

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“…The large potential health benefit from tailored care strategies in the subgroup with co-occurring alcohol misuse, smoking, and depression could warrant additional systems and provider burdens they may impose. Indeed, it has been suggested that refining screening, surveillance, and treatment strategies for this subgroup such as making them more patient-centered and prioritized, has great potential to improve population health [8]. But no group has considered whether discontinuation of one behavior is associated with the discontinuation of these other behaviors, a question of central importance in the efficient and effective design of interventions.…”

Section: Introductionmentioning

confidence: 99%

Do Alcohol Misuse, Smoking, and Depression Vary Concordantly or Sequentially? A Longitudinal Study of HIV-Infected and Matched Uninfected Veterans in Care

et al. 2015

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We analyzed temporal patterns of alcohol misuse, smoking, and depression among veterans in care to determine whether these conditions vary concordantly or sequentially. Using the Veterans Aging Cohort Study, harmful alcohol use (AUDIT-C ≥ 4), current smoking, and depression (PHQ-9 ≥ 8), were measured. In regression analyses, predictors included each outcome condition at baseline, the other two conditions in the same survey, the other two conditions in the immediately preceding survey, number of years since enrollment, and HIV status. We found that current smoking and depression were more common among HIV infected individuals. Harmful alcohol use was more common among uninfected individuals. Temporal analyses suggested a concurrent pattern: each condition was associated with the other two conditions (p < 0.03, OR 1.12–1.66) as well as with the prior presence of the same condition (p < 0.0001; OR 6.38–22.02). Smoking was associated with prior depression after controlling for current depression (OR 1.16; p = 0.003). In conclusion, alcohol misuse, smoking, and depression were temporally concordant and persistent, raising the question of whether they constitute a common syndrome in HIV infected patients and others with chronic diseases.

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“…1–11 The potential benefit from these clinical interventions may not be achieved for many years, but the potential harms may occur in the short term. 3,4,7,12 Thus, without considering long-term prognosis , defined as prognosis regarding life expectancy in the range of years, patients with limited life expectancy may be inappropriately exposed to harm from continued clinical interventions with little chance of benefit, whereas stopping these interventions in healthy older adults with long life expectancy may exclude them from potentially beneficial interventions.…”

mentioning

confidence: 99%