Confronting the Need for Evidence Regarding Prevention.

Grossman DC, Kemper AR.
Pediatrics. 2016 Feb;137(2):1-3. doi: 10.1542/peds.2015-3332. Epub2016 Jan 12. PubMed PMID: 26759409.

When both of us entered pediatrics, we learned that screening dipstick urinalyses was a standard part of well-child care, even though data from at least the 1970s questioned its rationale based on the high false-positive rate and the identification of self-limited disease.1 Screening seemed sensible and innocuous, and neither of us questioned it at the time. Although we were both aware of the debate about benefit, we do not recall hearing about the potential harms of dipstick screening. Over time, the evidence regarding the lack of benefit grew and the recommendation for screening urinalysis was limited to the 5-year-olds2 and then eventually dropped.3

Here is the question: Should a screening test that seems effective be adopted into routine practice with the expectation that evidence would eventually affirm its use or remove it from clinical care? Do we “do first, ask later?” We all know practices in our communities that still routinely use screening urinalyses out of concern about missing a “case” regardless of the potential harm and questionable benefit. How much do we need to know about a preventive screening test before it is recommended as “standard of care?” When do we know enough to either start or stop a service provided to all? How well do we stop a preventive service after it is shown to be ineffective?

Preventive care services delivery is the cornerstone of pediatrics. From the newborn visit through adolescence, the American Academy of Pediatrics (AAP) and Bright Futures recommend 31 well-child care visits, each with specific discrete preventive services.4 We are often asked by our trainees in clinic how we decide what services to provide within the limited available time. We were taught by skilled and talented clinicians based on their personal knowledge, experience, and expert opinion about what …