Revisiting routine screenings. The year 2013 showed a sharp trend away from recommendations for routine screening for certain diseases, but controversies surrounding such recommendations are likely to continue. Here are two prime examples.
- The latest guidelines from the American Urological Association, based on a systematic literature review, discourage prostate cancer screening in men either younger than 55 or older than 70. Men 55 to 69 benefited most from prostate-specific antigen (PSA) screening at two-to-four year intervals. One man per 1,000 screened for PSA elevations in this age group will avoid a prostate cancer death in 10 years. For more on this issue, see last January's AJN Reports (http://bit.ly/VDh8HK).
- Studies continued to add to the debate about the effectiveness of breast cancer screening. An analysis of more than 30 years of data in the United Kingdom, published in June's Journal of the Royal Society of Medicine, found that having mammograms didn't reduce deaths from breast cancer. Another study, in the June 11 British Journal of Cancer, showed that screening could lead to overdiagnosis and overtreatment; by one estimate, for each breast cancer death prevented by mammography, three patients are overdiagnosed and treated—a chance many women in the United Kingdom are presumably willing to take. Nevertheless, many physicians don't warn patients of screening risks, and according to a research letter in JAMA Internal Medicine (online October 21), when patients were warned of risks, most of the information was inaccurate. The other side of the argument? A retrospective analysis published online in Cancer (September 9, 2013) of women diagnosed with breast cancer in the 1990s and followed through 2010 showed that 71% of breast cancer deaths occurred in women 40 to 49 who didn't receive mammograms, supporting the argument for regular screening before age 50.
Gun violence. Each year, 31,000 people in the United States die from firearms, and extensive media coverage of several mass shootings this year revived attention on—and controversy over—gun control and mental health treatment needs.
There are few data that actually connect mental illness with firearm deaths, but gun laws do appear to make a difference: states with the most firearm laws reported the lowest firearm homicide and suicide deaths between 2007 and 2010, according to a report in JAMA Internal Medicine (May 13, 2013).
And a study of 27 developed countries found that per capita gun ownership correlated strongly with rates of gun-related deaths; the rate of gun ownership was highest in the United States, and not surprisingly, so was the rate of gun-related deaths.
Responding to an executive order from President Obama, the Institute of Medicine published research priorities for reducing gun violence (http://bit.ly/18Or1Kf) to establish scientifically sound public health policies on the issue.
Whether better funding for mental health care could help prevent gun violence wasn't addressed in the report. For more on mental health and violence, see this month's Mental Health Matters.
Chronic diseases. Life expectancy in the United States has increased because of advances in treatment for infectious diseases; however, treatments for chronic diseases, many of which are preventable, consume 75% of U.S. health care spending. For example, half of all U.S. adults have at least one chronic illness, and one in three is obese; heart disease, cancer, and stroke account for half of all deaths; cigarettes cause almost all lung cancer deaths; and diabetes is the leading cause of kidney failure and amputations. A lack of exercise, poor nutrition, smoking, and excessive alcohol use cause most chronic diseases (see an overview from the Centers for Disease Control and Prevention at http://1.usa.gov/9QBepF).
As the year proceeds, expect to see providers and policymakers paying more attention to chronic-disease care.
End-of-life care. Quality of life among people approaching death is better if they're not hospitalized, sent to ICUs, or placed on feeding tubes. But as the population ages, particularly with the chronic diseases outlined above, more efforts will be needed—and soon—to ensure more timely transfer of patients to hospice when costly and futile care cannot result in a cure. Although twice as many Medicare patients died in hospice in 2009 as in 2000, for example, many remained in ICUs for anywhere from three days to a month before reaching hospice.
Patients who have end-of-life talks with caregivers receive more hospice care more often, but palliative care often remains an add-on rather than a plan arrived at through discussion among physicians, patients, and families.—Carol Potera and Gail M. Pfeifer, MA, RN, news director