Every year new medical recommendations and guidelines are released which are intended to improve healthcare, universalize practices across the country, and simplify patient care. As a provider, I can attest that generally these guidelines do just that but occasionally not all the sources agree on the proposed changes. Therein lies the problem and resultant controversies such differences potentially evoke like the mammography recommendations by the United States Preventative Services Task Force in 2009.
Over the last couple of years and months, a few changes in medical practice have been recommended and providers are slowly implementing these new guidelines. For example, pap smears, routine screening tests in women to check for cervical cancer, are now every three to five years instead of yearly. Pap smears without HPV (human papilloma virus) testing are recommended for women between the ages of 21-30 every three years. Pap smears with HPV testing are recommended for women over age 30 and can span every five years if HPV testing is negative. This change was instituted because of the high prevalence of HPV in the general population, particularly in younger women, and the association of HPV with cervical cancer. Women over age 65 will no longer need to be screened for cervical cancer.
Recently the American Heart Association and the American College of Cardiology proposed changes for who would benefit from cholesterol medications. In the past, the initiation of meds was based solely on current health conditions and total cholesterol, LDL, and HDL levels but now the focus will be on four main issues:
1. Do you have diabetes?
2. Do you have atherosclerotic disease?
3. Is your bad cholesterol (LDL) higher than 190?
4. Are you between the ages of 40 and 75 and have a 10-year estimated cardiovascular risk of 7.5% or higher?
If “yes” was the answer to any of those questions the new guidelines would recommend starting a moderate to high intensity statin medication. With these latest criteria, many additional individuals will qualify for therapy and while others will no longer need the cholesterol lowering agents. Likewise, this also means that fewer lipid panels will need to be drawn because providers do not need to follow cholesterol levels as routinely once therapy has been started.
In December, the panel members appointed to the Eighth Joint National Committee released the latest hypertension guidelines which included some less stringent blood pressure thresholds for the elderly and a slight variation in recommendations for initial hypertension management. For example, in people over the age of 60, blood pressure management should begin if pressures are 150/90 or higher. Previously, therapy would have begun at a blood pressure elevation of 140/90 per the JNC-7 guidelines. In addition, in the general black population, initial therapy should either be with a calcium channel blocker or a diuretic (water pill). Previous guidelines recommended that all populations start with a diuretic.
My patients often ask me how these experts establish these guidelines and by what method. In regards to the hypertension and cholesterol recommendations, the authors looked at the evidence surrounding outcomes from previous studies. The bottom line: did the medication or treatment change morbidity or mortality?
Of course any new recommendations are not without its naysayers and plenty of doctors across the country are weighing in on the discussion. However, I think these guidelines give patients an opportunity to engage in open dialogue with their primary care providers about their individual care plans and if they are within the correct targets for their ethnicity, age or disease state. Patients should empower themselves and also try to stay current with these rapidly changing recommendations. Optimum healthcare should be team oriented with the patient as the center of that team.
On the other hand, I caution individual patients not to stop any of their medications based on these guidelines alone but to schedule an appointment with your provider to discuss. Every patient is different and only you and your provider know what is best for you. Guidelines are intended to be tools and should be used appropriately in order to achieve the stated goals.
Yours in Service,
Denise Hooks-Anderson, M.D.
SLUCare Family Medicine
Special to the NNPA from the St. Louis American