In defense of the NHS clinical guideline, a Department of Health “spokesperson” explained that “an expert committee found that screening in women aged under 25 does more harm than benefit…Cervical cancer and mortality from it are very rare in women under 25. Since the starting age was raised in England in 2003 there has been no increase in mortality in women aged 20 to 24 or 25 to 30 years old.”

Claims about harm and benefit depend upon how those harms and benefits are distributed. Most routine screening increases health care expenditures. When individuals spend their own money on a test, they decide whether the tradeoff of less money for other uses is worth buying a test that reduces their personal risk.

To officials steeped in public health techniques emphasizing population health over individual medicine, individuals may carry less weight than budgets and population averages. Reducing screening reduces expenditure, and the harm from a rare death does not make its way into budgetary calculations. Implicitly assuming that ignorance is bliss, arguments for reducing screening often focus on the harm done by excessive treatment for minor abnormalities. They do this despite the fact that individuals making an informed decision about their future care always have the option to do nothing. They also discuss the “cost” of the mental distress caused by a false positive test, generally without weighing this mental distress against the mental distress caused by a cancer death that might have been prevented by early screening.

Official statistics report that the incidence of cervical cancer fell in England between 1998 and 2008 in all age groups except those aged 20 to 29. In 2008, there 39 were cases in the 20-24 age group and 281 cases in those aged 25-29. Since 2003, cervical incidence may have risen for those aged 25-34. It is clear, however, that cervical cancer mortality rates rose between 1998 and 2008 for the 25-29-year-old age group.

The U.S. Preventive Services Task Force says that survival rates for cervical cancer depend heavily on early detection. Infection with high-risk strains of HPV, generally acquired sexually, is “the most important risk factor for cervical cancer.”   Sexual activity with multiple partners, and intercourse at an early age, are also important risk factors.

To people exercising judgment, this might suggest that guidelines in touch with reality should encourage young women who start having intercourse at an early age to start Pap tests at an early age, especially since progression from cellular abnormalities to cancer between screening intervals is a bigger risk for women under 45. According to the U.S. Preventive Services Task Force, when annual Pap tests are recommended, “progression is rare; with 3-year intervals, this may happen in up to 50% of diagnosed cases.”

The good news is that U.S. Pap test guidelines prior to 2009 did encourage people to exercise judgment by recommending that women have their first Pap test 3 years after they began having sexual intercourse. This changed in November, 2009, when the American College of Obstetricians and Gynecologists (ACOG) released new guidelines. Despite data suggesting that U.S. women have become sexually active at younger ages since 1980, it recommended that women have their first Pap test at age 21. Adolescents, it tells us, have a very low risk of cervical cancer.

It is important to understand that although groups in favor of binding clinical guidelines like to talk about evidence-based recommendations, the evidence that they base their recommendations on may be weak or nonexistent. In 2005, the Ontario Program in Evidence-based Care  concluded that although five of the clinical practice guidelines it studied made “recommendations regarding the age of initiation of screening (recommendations varied between 20 and 25 years)… there were no comparative or non-comparative studies identified that addressed the initiation of screening.”

In the absence of data, one might expect that expert opinion would, like the pre-2009 guidelines, stress the importance of individual risk factors.  Unfortunately, as the influence of the public approach to medicine grows, this approach seems to have fallen out of favor.

Assuming that you were paying for the test, what Pap test guidelines would you recommend for your teenage or twenty-something daughter?

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She looked at me sternly. “You’re not calling your doctor,” she said. “I’m calling our doctor.” We were stunned…

“I have a Nexium,” a male voice said from two rows back.

I exhaled. “You are a life-saver,” I said.

“You can’t give it to her,” the flight attendant told the man.

I turned to Nexium Man. “You’re going to give it to me, right?” I pleaded.

“No.”

“No?”

“No. I’m a pilot for this airline and whatever she says…goes.”

Read the full story here.

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In fact, 12 percent of sicker patients reported not visiting a doctor due to cost concerns, compared with just four percent of other Canadians. Over a quarter of health-care services are paid for through private sources, either out-of-pocket by patients or through private insurance.

The survey also found that this group of patients fares worse when it comes to coordination of care. People with chronic conditions are likely to see multiple providers and specialists, yet many said they didn’t always receive help from their doctor’s office in coordinating that care.

About half of patients had to wait a month or longer to see a specialist, while almost one-quarter said test results or medical records were not available when they arrived for their appointments.

Full article on reduced access to care for Canadians.

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• Wait times between 2010 and 2011 increased in both the delay between referral by a general practitioner to consultation with a specialist (rising to 9.5 weeks from 8.9 weeks in 2010), and the delay between a consultation with a specialist and receiving treatment (rising to 9.5 weeks from 9.3 weeks in 2010).
• The report calculates that, in 2011, the average wait for an appointment with a specialist after being referred by a general practitioner was 156 percent longer than in 1993, and 70 percent longer to receive treatment after seeing a specialist.

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Almost two thirds of Americans have trouble getting care on nights, weekends, and holidays. You know what? A significant amount of the week is filled with nights, weekends, and holidays….

It’s fine to believe that people should try and see the doctor in the office. But if you want that to happen, then you need the office to be available. If retail clinics do a much better job in that respect, you can’t complain when people make use of them.

Full post on the convenience of retail clinics here.

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Full article on urgent care clinics.

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One disappointing finding in the RAND study had to do with patients of retail clinics in federally designated Health Professional Shortage Areas, places the government deems to have too few medical providers. There has been some hope that, with retail giants like CVS and Walmart being more ubiquitous than doctor’s offices, they could help bridge that gap in medical care. The study found no association, however, between primary care physician availability and retail clinic use.

Yet this problem might well be solved if Medicare adopts the advice given by Tom Saving and yours truly and pays market rates for seniors. Similar advice should be followed by Medicaid. See our previous post and additional links.

The study was published in the American Journal of Managed Care.

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Persons with disabilities report having much poorer access to care as those without disabilities. This is true even among those with health insurance. Those are some of the findings from the latest paper of which I am a coauthor with Lisa Iezzoni and Steve Pizer. It appears in the Disability and Health Journal.

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“The state has exchanged public funding for private, under-the-table payments,” said Lycourgos Liaropoulos, a professor at the University of Athens and a prominent health-care economist. A study by Mr. Liaropoulos and his colleagues found that Greeks spend nearly as much on bribes and other “informal” payments as they do on “formal” costs such as insurance co-pays

WSJ article here.

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