Annals of Family Medicine -- Comments for Østbye et al., 1 (4) 209-217

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Original Articles:
Truls Østbye, Gary N. Greenberg, Donald H. Taylor, Jr, and Ann Marie M. Lee
Screening Mammography and Pap Tests Among Older American Women 1996–2000: Results from the Health and Retirement Study (HRS) and Asset and Health Dynamics Among the Oldest Old (AHEAD)
Ann Fam Med 2003; 1: 209-217 [Abstract] [Full text] [PDF]

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Electronic letters published:

Prioritizing preventive services to optimize health: Steven H Woolf (1 December 2003)

Prioritizing preventive services to optimize health 1 December 2003

Steven H Woolf,
Fairfax, VA, USA
Professor of Family Practice, Virginia Commonwealth University
Send response to journal:
Re: Prioritizing preventive services to optimize health

The excellent paper by Ostbye and colleagues highlights the frustrating misallocation of resources in the delivery of health care in the United States. They show that a large proportion of older women are receiving screening mammograms and Pap smears, a practice that should not be viewed as inherently inappropriate--the U.S. Preventive Services Task Force recommends mammograms in this age group for women with a life expectancy of at least 10 years, and Pap smears for women age 65 and older who have not had regular screening exams with normal results for 10 years- -but probably represents some degree of over-screening. The authors discuss the potential cost implications to society.
A closer look at their data reveals that, across age groups, the lowest rates of screening are among those with poor socioeconomic status: the poor and poorly educated. Women who are likely to benefit much more from screening are less likely to do so because of barriers associated with their disadvantaged circumstances. Programs to overcome those barriers are struggling or collapsing due to financial pressures and tax cuts. The nation might save more lives if the resources consumed to provide screening to elderly women who will receive neglible or modest benefit were shifted to programs that deliver screening to those in greater need.
These rational considerations ignore the realities of how such choices are made, however. Unlike in European society, Americans are reluctant to reduce access to achieve equity. In some cases this is because of distaste for "rationing" (although the current situation also represents rationing, only by social status). But, as the study by Smith and colleagues in this issue demonstrates, a more common objection is the engrained perception of Americans that screening tests are inherently beneficial, regardless of the target condition or the age of the patient. Epidemiologic arguments ring hollow to those who see everything to gain and nothing to lose by getting tested, and reframing that perception remains an important challenge for the future.
Competing interests: None declared