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Implementation: the final frontier of preventive medicine

The experiences of the first and second USPSTF, as well as that of other evidence-based guideline efforts, have highlighted the importance of identifying effective ways to implement clinical recommendations. Practice guidelines are relatively weak tools for changing clinical practice when used in isolation (29,30). To effect change, guidelines must be coupled with strategies to improve their acceptance and feasibility. Such strategies include enlisting the support of local opinion leaders, using reminder systems for clinicians and patients (31), adopting standing orders, and audit and feedback of information to clinicians about their compliance with recommended practice (30).

In the case of preventive services guidelines, implementation needs to go beyond traditional dissemination and promotion efforts to recognize the added patient and clinician barriers that affect preventive care. These include clinicians' ambivalence about whether preventive medicine is part of their job, the psychological and practical challenges that patients face in changing behaviors, lack of access to health care or of insurance coverage for preventive services for some patients, competing pressures within the context of shorter office visits, and the lack of organized systems in most practices to ensure the delivery of recommended preventive care (32,33).

Failure to deal adequately with these challenges is a likely explanation for continuing gaps between USPSTF recommendations and clinical practice. Studies suggest that primary care physicians have variable but generally low awareness of and compliance with USPSTF guidelines (34,35,36). USPSTF recommendations have also had less influence on prevention-related legislation and policy than the highly visible efforts of advocacy groups (37). Under the Balanced Budget Act of 1997, Congress added several preventive services under Medicare, but only one of these (colorectal cancer screening) was recommended for routine use by the Task Force (38). Similarly, a recent survey of state legislation regarding cancer screening (39) shows many more examples of state-mandated coverage of prostate cancer screening (not recommended by the USPSTF) than of colorectal cancer screening. A recent Institute of Medicine report acknowledged these issues when it recommended a more objective and systematic approach to expanding Medicare coverage of preventive services recommended by the USPSTF (38). While the USPSTF and AHRQ will work to make their products more relevant to policymakers, these examples also illustrate that factors other than scientific evidence continue to shape policies in both the public and private sectors.

Neither the resources nor the composition of the USPSTF equip it to address these numerous implementation challenges, but a number of related efforts seek to increase the impact of future USPSTF reports. The USPSTF convened representatives from the various audiences for the Guide—clinicians, consumers, and policymakers from health plans, national organizations and Congressional staff—about how to modify the content and format of its products to address their needs. With funding from the Robert Wood Johnson Foundation, the USPSTF and Community Guide Task Force conducted an audience analysis to further explore implementation needs. The Put Prevention Into Practice (28,40) initiative at AHRQ has developed office tools such as patient booklets, posters, handheld patient mini-records, and a new implementation guide for state health departments and clinical settings (41).

Dissemination strategies have also changed dramatically in this age of electronic information. While recognizing the continuing value of journals and other print formats for dissemination, AHRQ will make all USPSTF products available through its Web site. The combination of electronic access and extensive material in the public domain should make it easier for a broad audience of users to access USPSTF materials and adapt them for their local needs. Online access to USPSTF products also opens up new possibilities for the appearance of the third edition of the Guide to Clinical Preventive Services. Freed from having to serve as the primary repository for all USPSTF work, the next Guide may be much slimmer than the almost 1,000 pages of the second edition.

National efforts such as the USPSTF face inherent limitations in trying to influence practice in individual physicians' offices. To be successful, approaches for implementing prevention have to be tailored to the local level and deal with the specific barriers at a given site, typically requiring the redesign of systems of care. Such a systems approach to prevention has had notable success in established staff-model health maintenance organizations, by addressing organization of care, emphasizing a philosophy of prevention, and altering the training and incentives for clinicians (42). Staff-model plans also benefit from integrated information systems that can track the use of needed services and generate automatic reminders aimed at patients and clinicians, some of the most consistently successful interventions (31,43). Information systems remain a major challenge for individual clinicians' offices, however, as well as for looser affiliations of practices in network-model managed care and independent practice associations, where data on patient visits, referrals and test results are not always centralized.

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Future challenges

The USPSTF faces continuing challenges in its attempts to distill evidence and produce clinical recommendations (go to the accompanying article on USPSTF methods) (44). Increasing explicitness of USPSTF methods cannot completely remove the subjective element involved in making recommendations based on inferences from imperfect evidence on complex issues. Nonetheless, the USPSTF continues to adhere to the general principle that it is appropriate to set a high standard of evidence for preventive care. Premature promotion of services that may be ineffective not only wastes time and money, but could also harm healthy patients, divert attention from more important issues, and undermine efforts to determine what really works.

Over time, the principal question of interest to the USPSTF in the past—Does the preventive service work?—has matured into more sophisticated questions about the magnitude of benefit, the trade-off between benefits and harms, and the influence of individual preferences on those trade-offs. The Task Force is developing principles for incorporating "shared decision making" into recommendations involving important trade-offs (e.g., tamoxifen to prevent breast cancer, which carries potential benefits and risks), as discussed below. As detailed in the article about methods, setting the threshold for what constitutes good evidence remains a formidable challenge.

There are inevitable tensions in translating conclusions about the evidence into recommendations that may be widely applied by clinicians in a variety of settings. One approach is simply to describe the quality of the supporting evidence for specific outcomes, leaving it to others to translate that into recommendations appropriate to their practices. This approach recognizes that decision-makers—whether clinicians, legislators, payers, or patients—confront different constraints and priorities in their individual settings. Conversely, blanket recommendations offer clearer guidance but impose the value judgments of the committee and give little account to other determinants of appropriateness (expert opinion, prior experience, standards of care, costs, resources, patient expectations, available services, insurance coverage, medical-legal liability, and ethics). Feedback from a variety of users has clearly indicated a desire for explicit recommendations from the USPSTF, but the group will continue to struggle with its dual duties to describe the evidence and advise on practice policy.

An important challenge is what position to take for the many services reviewed by the USPSTF when available evidence is inadequate to assess the net benefits or harms. Some say the USPSTF should take a neutral position and offer no advice until better evidence becomes available. Others say it should be more permissive, offering such services as "clinical options," especially if the potential harms or costs are minimal. Doing so recognizes that science is only one consideration in judging appropriateness and that clinicians cannot always await better data to make a decision. Some argue the opposite: In an era in which preventive services of proven benefit are not delivered because of limited time and resources, the USPSTF should actively recommend against use of interventions that have not been adequately studied.

For a growing number of preventive services, available data are sufficiently robust to quantify the magnitude of benefits and harms for specific population groups, but this precision gives rise to difficult ethical questions about trade-offs (45). If a preventive service poses potential benefits and harms, some would recommend that the USPSTF avoid making any generic recommendations and instead uniformly advocate shared decision making, in which the clinician reviews the trade-offs with patients and helps them decide for themselves based on personal preferences. This approach, however, may be impractical and ethically unnecessary except for "close calls" in which judgments about whether benefits outweigh harms fluctuate dramatically based on personal preferences. Even in those cases, a large proportion of patients expects the clinician to give advice (46). Perhaps the USPSTF has a duty to proffer what that advice should be.

When the original USPSTF was established in 1984, it received explicit instructions not to consider the economic costs of preventive services. Recommending against an effective service because of its cost was considered unpalatable, econometric methods were immature, and controversy over costs could distract attention from more fundamental questions of effectiveness. Although modern methods of cost-effectiveness analysis still need refinement, it is now much more acceptable (in theory, at least) to consider costs in health policy. Here too, however, the role of the USPSTF continues to evolve. At present, the Task Force is reviewing published cost-effectiveness studies and subjecting them to critical appraisal according to accepted criteria, but there is interest in conducting its own analyses when published data fail to address questions of interest. Furthermore, questions of when and how the USPSTF might alter recommendations based on cost effectiveness are not resolved. If economic considerations will influence recommendations, what threshold of cost effectiveness or cost utility is considered acceptable? These issues are explored more fully in the accompanying article on cost effectiveness (47).

Finally, for the services the USPSTF does recommend, it is clear that clinicians, health care systems, and payers cannot implement everything at once. For priorities to be set in an evidence-based manner, the USPSTF sees the need for providing users with quantitative information about the relative benefits to individuals and populations. This would require converting the outcomes of preventive services to a common metric, such as quality-adjusted life-years, so that interventions that reduce morbidity or mortality can be compared on a level playing field. Although the USPSTF has decided to include outcomes tables in its reviews with the primary data on which such calculations would be based, views differ on whether it should undertake the additional role of ranking the relative priority of preventive services. The Partnership for Prevention convened a panel to develop methods for prioritizing services. The rankings of the services recommended in 1996 by the second USPSTF are expected to be published in 2001 (48).

The approach the USPSTF is currently taking in dealing with these issues is addressed more fully in the articles that follow. The details of this process, however, flow from fundamental philosophical choices about the roles and responsibilities outlined above, which will remain matters of discussion, debate, and learning for years. As the USPSTF makes adjustments in its sense of purpose to better serve the needs of patients and providers, its methods and procedures can be expected to develop accordingly.

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References and Notes

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Author Affiliations

[a] Woolf: Virginia Commonwealth University, Medical College of Virginia, Fairfax, VA.
[b] Atkins: Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, Rockville, MD.

Copyright and Source Information

This document is in the public domain within the United States as stated in AHRQ's license agreement with the American Journal of Preventive Medicine. For information on reprinting, contact Randie Siegel, Director, Division of Printing and Electronic Publishing, Agency for Healthcare Research and Quality, Suite 501, 2101 East Jefferson Street, Rockville, MD 20852. Requests for linking or to incorporate content in electronic resources should be sent to: https://info.ahrq.gov.

Source: Woolf SH and Atkins D. The evolving role of prevention in health care: Contributions of the U.S. Preventive Services Task Force. Am J Prev Med 2001;20(3S):13-20 (http://www.elsevier.com/locate/ajpmonline).

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