I always liked poetry, but I was never a poet. I had to marry into that.

Multiple components of the healthcare and public health systems are currently under scrutiny. One of them is reportedly the U.S. Preventive Services Task Force (USPSTF: “Task Force”), established in 1984 and managed by the Agency for Healthcare Research and Quality. 

It was created to maintain an ongoing evaluation of disease prevention and screening interventions that are relevant to general clinical practice. 

Given the intended setting of implementation of its analyses, the members are generalist clinicians and methodologists steeped in the practice of evidence-based medicine. They are carefully vetted for potential conflicts of interest and recused from discussions or voting for substantive dual interests. The members work in tandem with experts in systematic evidence reviews and meta-analysis in generating every recommendation.

For about two decades, I served as a federal liaison to the Task Force, first as the director of the NIH Office of Disease Prevention and then as director of the NCI Division of Cancer Prevention. 

As a cancer specialist, I would never have qualified to be a member of the Task Force. I believe that was appropriate because the purview of most specialists is more restricted than that of general practitioners, who must consider the broad range of preventive and screening interventions for their patients, each with potential benefits and harms. 

Nevertheless, I attended nearly every meeting of the Task Force for about 20 years, and that has given me some perspective on its process and its value. Deep understanding of the Task Force methods is, in my opinion, critical prior to initiating radical changes to its process or composition.

The USPSTF is a jewel within the government, notable for its rigor and transparency at each step in its data analysis and subsequent communication of its guidelines. 

Throughout, it has relied on a transparent analytic framework that links healthcare interventions in a prospectively specified target population to true health outcomes (disease-specific mortality, overall mortality, improved quality of life, and observed harms) rather than less reliable “surrogate” endpoints of uncertain linkage to actual health. 

They put emphasis on randomized controlled trials, but the criticism that they ignore other forms of evidence is unfounded. For example, a reliable assessment of harms can be derived from well-controlled cohort studies. 

Of course, any process should evolve with experience and re-evaluation, and the Task Force is no exception. I watched that happen during my two-decade tenure as a liaison. For example, the Task Force revised its approach to Recommendation Statements in 2019.

The USPSTF is a jewel within the government, notable for its rigor and transparency at each step in its data analysis and subsequent communication of its guidelines. 

Most of the changes have been incremental, such as the increasing use of formal decision models to supplement systematic evidence reviews. These models have sometimes prompted Task Force Members to issue guidelines that inch beyond the age range or underlying risk status of the populations studied in definitive randomized clinical trials.

Some changes have been more sweeping, such as the rule in the 2010 Affordable Care Act mandating full coverage without co-pays of guidelines judged with confidence to have a high or moderate net benefit for patients (i.e., Grade A or B recommendations). 

That legislation fundamentally changed the role of the Task Force, transforming its recommendations for practice into guidelines with the teeth of policy. 

That foreseeably has had two consequences. On the plus side, the law improved access to a broad range of preventive services and disease screening that were underused because of financial barriers. On the other hand, translating recommendations into policy eventually and inevitably slides into politics. 

Stakes are heightened for specialty societies and disease-specific advocacy groups. Politicians clamor for changes in the Task Force composition, methods, and outcomes. 

Such political pressures may ultimately become too much to bear for even the most rigorous scientific methods, and “facts” become more dependent on ideology and financial considerations.

That environment periodically leads to accusations that the USPSTF leans left or leans right in the political spectrum. I believe that neither is true: It leans on data and the transparent analytic framework that has served it well for four decades. 

I have not always agreed with their recommendations, but I harbor faith in the rigor of the process and the systematic approach to evidence gathering and evaluation across the spectrum of its recommendations. 

Is there room for improvement and further evolution? Yes. 

For example, the process of converting practice recommendations and guidelines into reimbursement policy could be separated, hopefully dissipating some heat on the Task Force members in their deliberations. 

In addition, there could be future research comparing the magnitude of net benefit of the multiple recommendations in order to achieve maximal overall net benefit and on assessment of opportunity cost trade-offs. 

But that is for future discussion. In the meantime, it’s important to keep in mind that polishing a jewel may enhance its value, but re-cutting it carries risk, especially in the hands of new jewelers.