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Prevention

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Researchers discuss preventive care recommendations from the third U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) is an independent panel, first convened in 1984 by the U.S. Department of Health and Human Services, to develop evidence-based recommendations for clinicians about preventive health care. The Task Force recommends which screening tests, immunizations, preventive medications, and counseling interventions doctors should routinely incorporate into clinical practice.

The third USPSTF was convened in late 1998 by the Agency for Healthcare Research and Quality. Four new screening recommendations from the Task Force are summarized in a recent clinical review by David Atkins, M.D., Coordinator of Clinical Preventive Services for AHRQ's Center for Practice and Technology Assessment. In a second article, Dr. Atkins and his colleagues examine USPSTF prevention care priorities, finding that the most highly recommended services are delivered at a low rate nationally. The articles are summarized here.

Atkins, D. (2001, April). "First new screening recommendations from the third U.S. Preventive Services Task Force." British Medical Journal USA 1, pp. 187-190.

The USPSTF only recommends that clinicians routinely provide preventive services for which the benefits substantially outweigh harms and for which there is good evidence that the service improves important health outcomes (for example, reduces the rate of death or disease). The third USPSTF recently made four new recommendations. First, doctors should screen women over 45 years, men over 35 years, and high-risk young adults for high blood cholesterol and low high density lipoprotein (HDL, so-called good cholesterol) levels. However, in treatment decisions—for example, use of statin drugs that reduce the risk of coronary heart disease—clinicians should consider each patient's overall risk of heart disease.

Second, clinicians should routinely screen sexually active women 25 years of age and younger for chlamydial infection to prevent pelvic inflammatory disease (PID) and its complications, such as tubal pregnancy and infertility. Chlamydial infection is the most common sexually transmitted bacterial disease in the United States. One trial showed that screening and treating at-risk women could reduce the incidence of PID by more than 50 percent.

The third Task Force recommendation says that screening for and treatment of bacterial vaginosis during pregnancy—a condition that increases the risk of preterm birth and low birthweight babies—is not beneficial in average-risk women but is an option for some women at high risk of preterm delivery. Fourth, although total body skin examination can improve detection of early skin cancer, the Task Force found insufficient evidence to determine whether it will reduce morbidity and mortality from skin cancer.

Reprints (AHRQ Publication No. 01-R088) are available from the AHRQ Publications Clearinghouse.

Coffield, A.B., Maciosek, M.V., McGinnis, M., and others. (2001). "Priorities among recommended clinical preventive services." American Journal of Preventive Medicine 21(1), pp. 1-9.

The prevention services most highly recommended by the USPSTF are delivered at low rates, according to this study. In fact, the Committee on Clinical Preventive Service Priorities assessed the value of 30 USPSTF-recommended services for average-risk patients as part of periodic health examinations. Priority standing was based on the burden of disease prevented by each service and its cost-effectiveness (cost of the service divided by quality-adjusted life years saved). The Committee ranked each service from 1 to 5 points on each of the 2 dimensions, for total scores ranging from 2 to 10. They then compared the highest ranking services with current delivery rates nationally.

The highest ranked preventive services (scores of 7+) with the lowest delivery rates (50 percent or less nationally) were: providing tobacco cessation counseling to adults, screening older adults for undetected vision impairments, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumonia. Two additional services, offering adolescents an anti-tobacco message or advice to quit and counseling adolescents on alcohol and drug abstinence are poorly delivered and of high potential value even if minimally effective. However, the evidence base supporting them is more limited.

On average, adult patients have about a dozen risk factors requiring about 24 preventive services. Yet, even the most well-intentioned clinicians and conscientious patients have difficulty including all recommended preventive services in a single visit. The priority ranking of recommended preventive services by these authors should help guide efforts of clinicians, as well as health care administrators and health plans, to set priorities for preventive care services. These priorities also should help State and local public health officials set priorities for high-risk groups, including those with less income and/or less education and those who belong to an ethnic/racial minority group, who are at higher risk for some preventable illnesses such as heart disease and stroke.

Reprints (AHRQ Publication No. 01-R087) are available from the AHRQ Publications Clearinghouse.

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