JAMA Forum: Lung cancer screening and evidence-based policy.

News & Analysis new patients to complete forms with ques- tions about their personal and family medi- cal history and marital status, but typically, the forms omit any questions about sexual orientation or gender identity, she says. “Right at the beginning, we discourage people from coming out.” Surveys have found that most physi- cians don’t ask about patients’ sexual orien- tation at their annual checkup, Eckstrand says. “Most providers don’t know to ask the questions,” Obedin-Maliver says. “Some pro- viders feel these questions are inappropri- ate, invasive.” When they do ask, there often isn’t a place for the answer in the electronic health record (EHR). In June 2013, the University of California, Davis, became the only academic medical center in the United States that has incorporated stan- dard questions about sexual orientation and gender identity within patients’ EHRs (Callahan EJ et al. Acad Med. doi:10.1097 /ACM.0000000000000467 [published online August 26, 2014]). “Specifically LGBT health centers around the country had been asking this question already, but no academic health center had,” says psychologist Edward Cal- lahan, PhD, associate dean for academic per- sonnel and professor of family and commu- nity medicine at the University of California, Davis. “I’ve talked to a large number of places around the country that are making efforts to do it. We’re the first, but we’re not going to be alone for very long.” Still, not all physicians at his institution see the need to ask, says Callahan, a mem- ber of the AAMC’s Group on Diversity and In- clusion, who at the top of his university home page notes that he welcomes LGBT pa- tients (http://bit.ly/1zR4UPN). “We’re still facing providers who think that it’s not rel- evant—the doctor who says ‘I treat all my pa- tients exactly the same,’” he says. “The real- ity is it does matter a great deal. People have different needs, different risks, depending on who they are.” Although the AAMC guidelines are aimed at medical school students and faculty, they could and should help inform training and continuing medical education for physicians, says Henry Ng, MD, president of GLMA (previously known as the Gay and Lesbian Medical Association). “I share with our trainees: people are held accountable for the care that they give—good, bad, or indif- ferent,” says Ng, an assistant professor at Case Western Reserve University School of Medicine, which has offered an elective in LGBT health since 2008. Ng, an internist and pediatrician, helped develop and currently serves as director of the MetroHealth Pride Clinic, the first in Ohio to serve the health care needs of LGBT individuals. The AAMC is already thinking about that, Nivet says. “What if we worked with some of the medical societies? What if we came up with modules that practicing phy- sicians could use?” Eckstrand doesn’t want to stop there. “I hope this can be translated into other health professions,” she says. “We are so proud of this work, but we think this is just the start- ing point.” The JAMA Forum JAMA Forum: Lung Cancer Screening and Evidence-Based Policy Andrew Bindman, MD American Medical Association M any people have dreamed of a day when health policy might be based less on the political clout of special interest groups and more on re- search evidence. Evidence-based health policy could lead to more rational decision- making than typically occurs today. For this to work, however, we need a process to col- lect and consider all of the relevant evi- dence before formulating a policy. The discussion surrounding the use of computed tomography (CT) scanning to screen for lung cancer is a case in point. The Affordable Care Act (ACA) in- cluded a provision that requires private health insurers to cover, at no cost to their beneficiaries, “[e]vidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF) . . . .” On its surface, this sounds like a logical approach for translating evidence jama.com from research on preventive services into policy. The ACA removes patients’ financial barriers to receiving the most efficacious pre- ventive services; it also requires health in- surers to invest in preventive care and cre- ates a level playing field for them to do so. However, the evidence that the USPSTF finds relevant for its recommendations is not the only thing important to consider in es- tablishing a policy on coverage for a poten- tial preventive service. Earlier this year, the USPSTF assigned a B rating to a recommendation for annual screening for lung cancer using low-dose CT scans for adults aged 55 to 80 years who have a 30 pack-year smoking history. The major evidence supporting this recommen- dation came from the National Lung Screen- ing Trial, a randomized study that found a 20% reduction in mortality over a 4-year pe- riod among those receiving up to 3 annual screening CT examinations compared with Andrew Bindman, MD those who received screening with chest ra- diographs. The B rating for the recommen- dation means that health insurers are re- quired to cover the cost of the screening JAMA January 6, 2015 Volume 313, Number 1 Copyright 2015 American Medical Association. All rights reserved.