U.S. task force leads the way on prevention recommendations: Basing public health decisions on science
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* Kim Krisberg

For more than 25 years, the U.S. Preventive Services Task Force has been a pioneer in the fields of prevention and primary care, examining the evidence and using strict criteria to make recommendations that are often the gold standard for clinical preventive services.

First convened in 1984 by the U.S. Public Health Service and now sponsored by the Agency for Healthcare Research and Quality, the task force has a reputation for being fiercely diligent about sticking to the evidence — a characteristic that has garnered acclaim, respect and, most recently, national controversy. Most people outside of health, medical and policy circles probably knew little, if anything, about the U.S. Preventive Services Task Force until November, when the group released recommendations against routine mammography for women ages 40 to 49, recommending that such screening begin at age 50.

The new recommendation was delivered with a wealth of supporting evidence, as well as a clear caveat that mammograms before age 50 should remain a decision between patient and doctor. But in the midst of the debate on U.S. health reform, the recommendation became a lightning rod for reform opponents touting fears of health care rationing and received critical backlash from professional and advocacy groups such as the American Cancer Society.

For a group that spends much of its time out of the public eye, its members were now asked to defend their work before congressional hearings, and eventually decided to edit how the recommendations were presented. It was a sharp lesson in public relations and the pitfalls of mixing science and politics, especially as current health reform legislation could bring big changes to the independent task force by formally bringing it into the policy-making process.

“I would say that if we have a bias, it’s toward a very strict adherence to the fundamentals of scientific evidence, which I think is the best bias to have,” said Bruce Calonge, MD, MPH, chair of the task force and chief medical officer and state epidemiologist at the Colorado Department of Public Health and Environment. “We’re passionate about prevention and passionate about getting it right.”

Throughout its work, the task force uses a highly structured approach and process for reviewing the evidence and translating it into recommendations, grading the strength of the evidence from an “A,” for strongly recommends, to an “I,” meaning there is insufficient evidence to recommend for or against. The task force tackles a wide range of health services, from using aspirin to prevent heart disease to clinic-based smoking interventions to obesity screenings, and develops the widely used “Guide to Clinical Preventive Services.” Across its work, the task force “evaluates the preventive services free from advocacy, politics and conflicts of interest…the decisions are made on the science alone,” Calonge told *The Nation’s Health.*

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/1/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/40/1/1.2/F1)

Registered medical assistant Ivonne Jacomino, left, checks Maria Vila’s blood pressure in Hialeah, Fla., in September. The U.S. Preventive Services Task Force recommends that adults regularly receive preventive screenings for high blood pressure.

Photo by Joe Raedle, courtesy Getty Images

“We depend on groups like the task force to evaluate the science behind prevention,” said Rob Gould, PhD, president of the Partnership for Prevention. “We particularly like the task force because since its founding, it’s focused on having experts uniquely capable and focused on the evidence.”

Calonge also serves on the Centers for Disease Control and Prevention’s Task Force on Community Preventive Services and described the two task forces as “sister” groups, noting the importance of addressing the “integration between systems of care and public health.” Steven Woolf, MD, MPH, a past member and advisor to the U.S. Preventive Services Task Force, said the group often applies public health principles when evaluating clinical services, using all the “essential ingredients of the public health perspective.” In fact, Woolf said he remembers headlines such as “more talking, less testing” after the 1989 release of the first edition of the “Guide to Clinical Preventive Services” — “it was a new notion…that we should be spending more time modifying behaviors rather than ordering tests,” Woolf said.

“(The task force has) been critical in developing methodologies for assessing effectiveness,” said former task force member Steven Teutsch, MD, MPH, chief science officer at the Los Angeles County Department of Public Health. “When we’re delivering services to people who are asymptomatic, we need to know the benefits and harms…and the (task force) is as unbiased as it can possibly be.”

Traditionally, the task force’s main audience has been primary care providers, though its recommendations have been integrated beyond the doctor’s office into professional societies, health organizations and medical school curricula. But if current proposals in the health reform bills now before Congress are enacted, the task force’s reach and make-up could change significantly. Under the proposals, the task force would become an official federal panel, its size would grow from 16 members to 30, it would be required to consult a new stakeholders board and its activities would be done in accordance with federal transparency rules. While the task force’s evidence-based reputation makes it a desirable partner in health reform, there is worry that it could impede the group’s independence. In a Jan. 7 letter to leading members of the House and Senate, the Partnership for Prevention welcomed a broader role for the task force, but also emphasized the “importance of preserving the independence of their priority-setting and decision-making processes.”

“I do have concerns that there will be a loss of independence,” said task force chair Calonge. “Whoever is leading the task force and its members will have to work ever so much more to maintain that core value of independent evaluation of the evidence free from politics, advocacy and conflicts. I don’t think it’s impossible, there’s just going to have to be extremely strong leadership.”

As for more transparency, Calonge said the “task force recognizes the need and embraces changes that will enhance our transparency,” though he notes that the task force already enforces an extensive peer-review process. He said a new stakeholders board could provide valuable input, though it “would be damaging to the task force for stakeholders to interpret or otherwise perturb the evidence itself.” Former task force member Teutsch noted that “it’s good if visibility is increased and if recommendations are considered by all stakeholders — that can only be a good thing.” But he added that the task force’s core attributes are worth protecting.

“Meetings are often characterized by frank discussion of scientific issues,” Teutsch told *The Nation’s Health.* “If the process becomes open to discussion and not as scientifically rigorous or as critical as it needs to be, the recommendations will almost invariably be influenced by other considerations…it would be a shame if the basic tenets of the task force end up getting compromised.”

Ironically, the flap over November’s mammogram recommendations may help the task force prepare for the possibility of more time in the public eye.

“A lot more effort needs to be put into communications and making sure the recommendations are clear but also sensitive to public sensibilities and the politics of the time,” said Woolf, a professor of family medicine at Virginia Commonwealth University and an APHA member. “But a bigger lesson is the lack of a forum for rational discussion of health policy. What started out as a misunderstanding of recommendations was blown out of proportion by the media, politicians, radio talk shows…what ended up being covered had little to do with the facts of the case.”

In fact, the November controversy only highlighted what makes the task force so unique, said Gould at the Partnership for Prevention.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/1/1.2/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/40/1/1.2/F2)

Among the many preventive measures examined by the U.S. Preventive Services Task Force is aspirin use for cardiovascular disease, which it supported in certain at-risk populations.

Photo by Leslie Banks, courtesy iStockphoto

“If you look back now at the recommendation, the controversy and the kinds of reactions we saw — what that response communicates to us is exactly the reason why you need a task force that’s totally focused on the science,” he told *The Nation’s Health.* “We have to make sure all those passions don’t unduly influence what the science is really telling us.”

For more information on the U.S. Preventive Services Task Force and its work, visit [www.ahrq.gov/clinic/uspstfix.htm](http://www.ahrq.gov/clinic/uspstfix.htm).

*   Copyright The Nation’s Health, American Public Health Association