Diana Petitti: Taking an Evidence-Based Approach to Public Health

"The one-size-fits-all approach is not a very good direction for not only preventive medicine but medicine in general."

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Diana Petitti's story.

Early in her career, Diana Petitti, MD, MPH, realized that she was more interested in taking care of populations of patients rather than individual patients. She was attracted to epidemiology and public health, which led to a position as an epidemic intelligence service officer for the Centers for Disease Control and Prevention after she completed one year of clinical training. "My career started as a risk factor epidemiologist and evolved into a career focused more on the delivery of healthcare, quality of care, and evidence-based medicine," Petitti says.

Historically, preventive medicine was a specialty in a field that very few people thought of going into, and that the public really wasn't aware of, says Petitti, who is professor of biomedical informatics at Arizona State University and professor of basic medical sciences at the University of Arizona College of Medicine.

But today, there is a new vitality to preventive medicine. "People are realizing that it is much better to keep people from getting sick in the first place than to try to make them better once they are sick," Petitti says.

She credits much of this awareness to the massive problem of obesity and hypertension that this country is grappling with. "People realize that we could have started earlier and prevented a massive amount of what is going to be morbidity," she says. "The obesity epidemic has focused both the public and medical profession on the potential of prevention and helping them realize that we don't need to let that happen again."

Follow the evidence
Petitti is also a strong proponent that the healthcare industry needs to constantly reevaluate its practices and treatments in light of new evidence. "It fits directly with not just preventive and evidenced-based medicine, but a broad attempt to apply the principles of evidence and more tailored care across the spectrum, from prevention all the way through treatment," she says. 

But changing the status quo is often easier said than done, as Petitti learned firsthand in November 2009 after the U.S. Preventive Services Task Force released new mammography guidelines. Petitti, who was vice-chairwoman of task force, ended up spending much of her Thanksgiving holiday that year preparing for a Congressional hearing prompted by the fallout the revised recommendations created.

"Certainly it was recognized that they were going to be controversial and it was going to be difficult to make changes to something that was a set of practices that were so widely embraced by advocacy organizations. But the response and reaction was way beyond anything that I anticipated," she says. "I was surprised at the degree of media attention and concern—almost hysteria—about these guidelines."

The original mammography recommendations were fairly vague, says Petitti. The guidelines were to do a mammogram in women age 40 years or older every one to two years.

The new recommendation was much more specific. It said to screen women age 50 to 74 every other year, and for women age 40 to 50 the decision to screen should be based on a discussion with their physician taking into account individual preferences," Petitti explains. In addition, the guidelines said specifically that "we really don't have evidence to make a firm recommendation about screening women over the age of 75," she says. 

The backlash to the revised guidelines was immediate. Headlines included "Breast-Screening Advice is Upended," "Breast Exam Guidelines Raise Furor," and "Political Fallout From the Mammogram Maelstrom."

The concern was that the new guidelines, which reversed a longstanding recommendation that women in their 40s automatically undergo an annual or biannual mammogram, would result in increased breast-cancer deaths among women in their 40s who forgo screening. In addition, there was a fear that insurance companies would immediately deny coverage for mammography for women age 40 to 49 who opt to have the test done.

The guidelines generated controversy because of the emotional nature of mammography, Petitti says. "Many people know someone who has had breast cancer or had breast cancer diagnosed with mammogram and who believes or feels that the mammogram saved the life of that person," she says. The release of the recommendations also came out at a time when there was a lot of political debate about healthcare reform. "People that were opposed to the healthcare reform bill really seized on it, inappropriately in my opinion, as an example of the government not letting you do what you wanted it to do," she says. "It would have been controversial no matter what but definitely became fodder in the cannon in the battle for healthcare reform."

Still, Petitti says that mammography is just one example of how the healthcare industry can ensure that it doesn't fall into the trap of, This is how we did it before, so we should continue doing it that way forever. In general, there is a desire to be much more specific and tailor recommendations more directly to a person's individual risk, she says. "If we look at personalized medicine, in reality the mammogram guidelines were an attempt to make more personalized recommendations about when to have mammography. The one-size-fits-all approach is not a very good direction for not only preventive medicine but medicine in general."

Looking back over the past year, Petitti says there have been some positive outcomes from the controversy the recommendations generated. For example, there has been a call for a broader effort to systematize the approaches for recommendations based on evidence, she says. It also shined a light on the issue of groups that have a vested financial interest in a certain kind of recommendation. "A lot of positive things came out of this even though it definitely ruined my Thanksgiving," Petitti says. "Anytime you are changing something there is going to be a backlash, but it still needs to happen."