Reply to my peers

Begin reviewing and replying to peer postings/responses early in the week to enhance peer discussion. Participate in the discussion by asking a question, providing a statement of clarification, providing viewpoints with a rationale, challenging aspects of the discussion, or indicating relationships between two or more lines of reasoning in the discussion. Always use constructive language, even in criticism, to work toward the 

goal of of positive progress.

As in all assignments, cite your sources in your work and provide references for the citations in APA format. You may use this APA Citation Helper as a convenient reference for properly citing resources or connect to the APA Style website through the APA icon below

Include references with peer responses

Question

Clinical practice guidelines use available evidence to develop recommendations that guide practice to improve patient care. 

Select a clinical practice guideline, based on your area of interest, from one of the web sites below or another site. Describe the following information from the guideline you selected. 

• Identify the name of the clinical guideline and date developed
• Identify the population
• Identify 3 recommendations found in the guideline
• Identify the grade or level of recommendation for the three recomendations identified and describe what the assigned grade or level means.
• How can you use the information from the guideline in your practice?

Peer #1

Identify the name of the clinical guideline and date developed

          The name of the clinical guideline chose is “Screening for Prostate Cancer”. The guideline was presented by the Journal of the American Medical Association in 2018.

Identify the population

          The population of the study applies to adult men in the United States population that does not have a previous diagnosis or that does not have symptoms of prostate cancer. The article further differentiates the population by separating the men into three groups. The first group consists of the general population of men aging from 55-69 years of age. The second group consists of men that are considered to have increased risk by race as well as a family history of prostate cancer. The last group consists of men of age that is equal to or greater than 70.

Identify 3 recommendations found in the guideline

          The first recommendation provided is for men with an age of 55 – 69 in the US without symptoms or a current diagnosis of prostate cancer. The researchers recommend that this population of individuals should be selected individually on if they should be screened for prostate cancer by use of prostate-specific antigen (PSA) testing (Grossman et al., 2018). Based on the current studies, this population has been recorded from past studies to only benefit minimally from being screened for prostate cancer by PSA (Grossman et al., 2018). Studies have demonstrated that during a thirteen year follow-up, only an average of 1.3 deaths have been prevented out of 1000 screens for prostate cancer in this group (Grossman et al., 2018). The evidence suggests that there are little to no reduction in all-cause mortality within this group with screening (Grossman et al., 2018). While the lifetime risk of getting prostate cancer in the United States is approximately 11%, the risk of dying from prostate cancer is 2.5% (Grossman et al., 2018). The studies also supplied evidence that traditional routine testing on these groups of men often have more negative consequences than benefits. Negative consequences include false positive tests, which result in unnecessary psychological harm, as well as further diagnostic tests that can result in negative outcomes (Grossman et al., 2018). The main diagnostic test that has been described to cause negative outcomes in this instance is a prostate biopsy. Often times a prostate biopsy is done to follow up a positive PSA test. The complications of the biopsy include pain, hematospermia (blood in the sperm), and infection (Grossman et al., 2018). The recommendation also suggests that even if these groups of men do have prostate cancer, the chances of it having negative aspects on their lives or causing their death are around 2.5% (Grossman et al., 2018). The studies provided in this recommendation also suggest that even if these men do in fact have prostate cancer, that most would never become symptomatic during their entire lifetime due to the slow growing nature of this type of cancer. So in this group of individuals, the testing may cause more risks than it does benefits. The treatments that are used to treat prostate cancer if positive however, have many negative side effects that can affect the individuals for the rest of their lives. Some of the complications of treatment include long-term urinary incontinence and erectile dysfunction. The recommendation for this group is for the provider to explain the benefits and harms of screening, and to proceed with a shared decision regarding testing (Grossman et al., 2018).

          A second recommendation refers to a higher risk group of individuals that include those that have a family history of prostate cancer or is African American (Grossman et al., 2018). These groups of individuals are considered much more likely to have a positive diagnosis of prostate cancer. While the two groups are higher risked to having prostate cancer, the USPSTF was unable to give a separate specific recommendation regarding the screening for these individuals (Grossman et al., 2018). They recommend that more studies be made to determine the risks and benefits for screening these individuals as well. However the researchers did state that an advance family history should be obtained from the males with a family history of prostate cancer, particularly those with metastatic prostate cancer, as they may need further education regarding the risks and benefits of screening (Grossman et al., 2018). The researcher’s state that doctors caring for these groups should discuss the details regarding screening so that they can appropriately decide if they wish to peruse testing as well.

          The third recommendation mentioned in the article is that men over 70, regardless of race or risk factors, should not be screened for prostate cancer (Grossman et al., 2018). The research suggests that these individuals have the highest risk of over-diagnosis and false positives. They also state that these individuals have a greater risk of complications by the screening used for diagnosis particularly regarding the prostate biopsy. Adequate evidence suggests that there is no benefit on prostate cancer mortality in this group by PSA screening.

Identify the grade or level of recommendation for the three recommendations identified and describe what the assigned grade or level means.

The recommendation for the first two guidelines discussed are both rated C. A recommendation of grade C means that the service should be selected on an individual basis regarding the patient and their presenting history. In this instance, education should be provided regarding the screening for prostate cancer by providing the patient with the risks and benefits associated. The doctor should discuss everything with the patient and make an individual recommendation with the guidance of the patient’s wishes. The American Urological Association recommends that these individuals with a life expectancy of 10 to 15 years be informed of the benefits and harms associated with screening, and to engage in a shared decision on how to proceed (Grossman et al., 2018).

          The third recommendation is regarding men that are equal to or over the age of 70. The recommendation is that these men should not be screened for prostate cancer (Grossman et al., 2018). This recommendation has a rating of D, which means that USPSTF recommends against testing in this group. Men over 70 have a much higher risk of over diagnosis as well as false positives for prostate cancer. Given that prostate cancer is slow growing, many of these individuals would have more detrimental effects from the treatment of prostate cancer than the actual cancer itself. The article discussed that men over 70 also have a high degree of competing mortality during prostate cancer treatment.

How can you use the information from the guideline in your practice?

            This study is very helpful in determining the benefit verses the risk of screening for prostate cancer for different groups of men. I feel that the article should be more wide spread to provide education on the current evidence regarding the potential harms of routinely obtaining PSA without discussing or knowing the risks involved. Men who are at the age for traditional prostate cancer screening should be provided with the information regarding the harms associated with the testing. The benefits should always outweigh the risks when performing tests or procedures. The evidence provided in this article sheds light upon the evidence that has been compiled regarding such a widespread practice.

References

Grossman, D. C., Curry, S. J., Owens, D. K., Domingo, K., Caughey, A. B., Davidson, K. W., … Tseng, C. (2018). Screening for Prostate Cancer. JAMA, 319(18), 1901-1913. http://dx.doi.org/10.1001/JAMA.2018.3710

Peer# 2

Identify the name of the clinical guideline and date developed

The guideline that I chose to focus on this week is called “Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication”. It was published November 13, 2016.

Identify the population

This guideline included three sets of population, and with all the populations the USPSTF considered these persons to be candidates for primary prevention interventions (Statin Use for the Primary Prevention, 2016). The first population are adults 40-75 years of age with no history of CVD, one or more CVD risk factors, and a calculated 10- year CVD event risk of 10% or greater. The second population includes adults who were 40-75 years of age with no history of CVD events, one or more CVD risk factors, and a calculated 10- year CVD event risk of 7.5% to 10%. The third and final population are adults 76 years and older with no history of CVD. It should be noted that in this guideline a risk factor for these populations who have a risk factor of dyslipidemia, that this was defined by an LDL-C level greater than 130mg/dl or a HDL-C level less than 40mg/dL (Statin use for the Primary Prevention, 2016).

Identify 3 recommendations found in the guideline

The first recommendation found in this guideline pertained to the first population. The USPSTF recommends that in this population a low-to-moderate dose statin for prevention of CVD events and mortality when all three criteria are met. The criteria include: Age 40-75, have one or more CVD risk factors such as dyslipidemia, diabetes, hypertension, or smoking, and have a calculated 10- year risk of CVD events 10% or greater. The second recommendation is that for the population who has a 10-year CVD event risk of 7.5% to 10%. The recommendation is that the clinician chooses whether to offer a low-to-moderate dose statin. This is due to a lower probability of disease and uncertainty in individual risk prediction (Statin Use for the Primary Prevention, 2016). This should reflect and assessment of patients’ specific circumstances (Statin Use for the Primary Prevention, 2016). The third recommendation found in this guideline states that there is insufficient evidence to assess the balance of benefits and harms for starting statin use for the primary prevention of CVD events and mortality that do not have a history of heart attack or stroke (Statin Use for the Primary Prevention, 2016).

Identify the grade or level of recommendation for the three recommendations identified and describe what the assigned grade or level means.

Describing the strength of a recommendation is an important part of communicating its importance to clinicians and other users (Statin Use for the Primary Prevention, 2016). Each recommendation received a grade. The grade for the first recommendation is a B. This means that the USPSTF recommends this service, and there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial (Statin Use for the Primary Prevention, 2016).The grade for the second recommendation was a C. This means that the USPSTF recommends offering or providing this service selectively and to individual patients based on professional judgment and patient preferences (Statin Use for the Primary Prevention, 2016). There is moderate certainty that the net benefit is small (Statin Use for the Primary Prevention, 2016). The grade for the final recommendation received an I. The grade means that the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms (Statin Use for the Primary Prevention, 2016). The evidence lacks quality and is conflicting. In this case the service is offered, the patient should understand the uncertainty about the balance between benefits and harms.

How can you use the information from the guideline in your practice?

In my practice many of our patients have risk factors for CVD, but with no history of events. The guideline sets recommendations of how to treat those patients. Patients must have their cholesterol screening including total cholesterol, LDL, and HDL to implement this guideline (Statin Use for the Primary Prevention, 2016). By using the parameters in this guideline, we can see by which population our patient falls into and what would be beneficial or possibly harmful to that individual patient. Periodical assessments and lipid screening are important to review possible risk factors for each patient.  

References

Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication (2016, November 13). Retrieved July 2, 2020 from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication#fullrecommendationstart