Abstract
BackgroundRecently, health screening recommendations have gone beyond screening for early-stage, asymptomatic disease to include “screening” for presently experienced health problems and symptoms using self-report questionnaires. We examined recommendations from three major national guideline organizations to determine the consistency of recommendations, identify sources of divergent recommendations, and determine if guideline organizations have identified any direct randomized controlled trial (RCT) evidence for the effectiveness of questionnaire-based screening.MethodsWe reviewed recommendation statements listed by the Canadian Task Force on Preventive Health Care (CTFPHC), the United Kingdom National Screening Committee (UKNSC), and the United States Preventive Services Task Force (USPSTF) as of 5 September 2016. Eligible recommendations focused on using self-report questionnaires to identify patients with presently experienced health problems or symptoms. Within each recommendation and accompanying evidence review we identified screening RCTs.ResultsWe identified 22 separate recommendations on questionnaire-based screening, including three CTFPHC recommendations against screening, eight UKNSC recommendations against screening, four USPSTF recommendations in favor of screening (alcohol misuse, adolescent depression, adult depression, intimate partner violence), and seven USPSTF recommendations that did not recommend for or against screening. In the four cases where the USPSTF recommended screening, either the CTFPHC, the UKNSC, or both recommended against. When recommendations diverged, the USPSTF expressed confidence in benefits based on indirect evidence, evaluated potential harms as minimal, and did not consider cost or resource use. CTFPHC and UKNSC recommendations against screening, on the other hand, focused on the lack of direct evidence of benefit and raised concerns about harms to patients and resource use. Of six RCTs that directly evaluated screening interventions, five did not report any statistically significant primary or secondary health outcomes in favor of screening, and one trial reported equivocal results.ConclusionsOnly the USPSTF has made any recommendations for screening with questionnaires for presently experienced problems or symptoms. The CTFPHC and UKNSC recommended against screening in all of their recommendations. Differences in recommendations appear to reflect differences in willingness to assume benefit from indirect evidence and different approaches to assessing possible harms and resource consumption. There were no examples in any recommendations of RCTs with direct evidence of improved health outcomes.
Highlights
Health screening recommendations have gone beyond screening for early-stage, asymptomatic disease to include “screening” for presently experienced health problems and symptoms using self-report questionnaires
The objective of the present study was to examine recommendations from three major national guideline organizations, the Canadian Task Force on Preventive Health Care (CTFPHC), the United Kingdom National Screening Committee (UKNSC), and the United States Preventive Services Task Force (USPSTF), to (1) document the consistency of recommendations on using questionnaires to screen for presently experienced health problems or symptom-based syndromes, (2) identify sources of divergent recommendations, and (3) determine if guideline organizations have identified any examples of direct evidence from randomized controlled trial (RCT) that questionnaire-based screening programs improve health outcomes for screened patients compared to non-screened patients
Identification and evaluation of direct evidence from RCTs described in recommendations We reviewed each recommendation statement and its accompanying evidence review and extracted the citations of all RCTs described as screening interventions; nonrandomized interventions were excluded
Summary
Health screening recommendations have gone beyond screening for early-stage, asymptomatic disease to include “screening” for presently experienced health problems and symptoms using self-report questionnaires. Since the 1960s, when screening for breast cancer with mammography was first tested, enthusiasm for the idea that some diseases can be prevented through early detection has resulted in an explosion in the number of screening tests that have been promoted, some with evidence of benefit and others without such evidence [3]. In addition to the goal of reducing risk of future ill health by detecting pre-clinical indicators of disease, the idea of screening has increasingly been applied to the use of self-report questionnaires to “screen” for existing health problems (e.g., alcohol misuse) or symptom-based syndromes (e.g., depression) that are not hidden; rather, they are experienced by patients, but not reported as health problems or observed by healthcare providers. Questionnaire-based screening has since been evaluated for other presently experienced health problems and symptom-based syndromes, including alcohol misuse, illicit substance use, intimate partner violence, and developmental delays in young children [5,6,7]
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