Preventive Service



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|US Preventive Services Task Force Recommendations for Adults |

|March, 2014 |

|Recommendation Key |

|Recommended |Insufficient evidence/No recommendation |Recommend Against |

|(A or B Grade) |(I or C Grade) |(D Grade) |

| |

|Preventive Service |General Population |High Risk Population |

| Screening | | |

| Body Measurement | | |

| Blood Pressure1 |? periodicity |No specific recommendation |

| Height/Weight/BMI2 |? periodicity |No specific recommendation |

| Bone Densitometry3 |F, >65, ? periodicity |F 35, F, >45, ? periodicity |M & F, >20, ? periodicity if at increased coronary heart disease|

| | |risk |

| |M, 24 weeks gestation |

| Thyroid Disease11 |Insufficient evidence |No specific recommendation |

| Anemia (iron deficiency)12 |Insufficient evidence |F, pregnant |

| Chronic Kidney Disease13 |Insufficient evidence |Insufficient evidence |

| Cancer | | |

| Breast (mammogram, clinical breast exam, |Mammogram: F, 50-75 q 2 yrs. |Family history breast, ovarian, tubal or peritoneal cancer. |

|genetic testing)14 | |Assess for risk with validated screening tool and refer for |

| | |genetic counseling if positive. |

| |Mammogram: F, 40-49, >75, clinical exam, MRI | |

| |Genetic testing: Recommend against | |

| Prostate (PSA)15 |Recommend against |Recommend against |

|Preventive Service |General Population |High Risk Population |

| Colorectal (High-sensitivity FOB yearly, |50-75 | 86 | |

| Cervical (PAP, HPV)17 |F, 21-65 q 3 yrs. 30-65 q 5 (PAP and HPV) |q 2565 at increased risk of falls—physical exercise or physical |

| | |therapy |

| Healthy Diet52 |Insufficient evidence |Hyperlipidemia or other diet-related risk factors—as part of |

| | |intensive counseling |

| Tobacco Use53 |All tobacco users |F, pregnant smokers—pregnancy-tailored counseling |

| |Ask, Advise, Assess, Assist, Arrange | |

| Alcohol Misuse54 |All > 18. Screen for misuse. If positive provide brief |No specific recommendation |

| |behavioral counseling interventions | |

| Skin Cancer Prevention55 |M,F > 24 or not fair complexion |M, F < 24 with fair complexion |

| Motor Vehicle Occupant Restraint56 |Insufficient evidence |No specific recommendation |

| Sexually Transmitted Infections (STIs)57 |Insufficient evidence |High risk for STIs |

Rationale

1 Blood Pressure. The USPSTF found good evidence that treatment of high blood pressure in adults substantially decreases the incidence of cardiovascular events. The USPSTF found good evidence that screening and treatment for high blood pressure causes few major harms. The USPSTF concluded that there is high certainty that the net benefit of screening for high blood pressure in adults is substantial. (2007)

2 Height/Weight/BMI. The USPSTF found good evidence that body mass index (BMI), calculated as weight in kilograms divided by height in meters squared, is reliable and valid for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. (2003)

3 Bone Densitometry. By 2012, approximately 12 million Americans older than 50 years are expected to have osteoporosis. One half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime; 25% of these women will develop a vertebral deformity, and 15% will experience a hip fracture. Osteoporotic fractures, particularly hip fractures, are associated with chronic pain and disability, loss of independence, decreased quality of life, and increased mortality. Although hip fractures are less common in men than in women, more than one third of men who experience a hip fracture die within 1 year. The USPSTF found convincing evidence that bone measurement tests predict short-term risk for osteoporotic fractures in women and men. The most commonly used tests are dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine and quantitative ultrasonography of the calcaneus. Adequate evidence indicates that clinical risk assessment instruments have only modest predictive value for low bone density or fractures. No controlled studies have evaluated the effect of screening for osteoporosis on fracture rates or fracture-related morbidity or mortality. In postmenopausal women who have no previous osteoporotic fractures, the USPSTF found convincing evidence that drug therapies reduce the risk for fractures. In women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors, the USPSTF judged that the benefit of treating screening-detected osteoporosis is at least moderate. Because of the lack of relevant studies, the USPSTF found inadequate evidence that drug therapies reduce the risk for fractures in men who have no previous osteoporotic fractures. The USPSTF identified the absence of randomized trials of primary fracture prevention in men who have osteoporosis as a critical gap in the evidence. The USPSTF found no new studies that described harms of screening for osteoporosis in men or women. Screening with DXA is associated with opportunity costs (time and effort required by patients and the health care system). Harms of drug therapies for osteoporosis depend on the specific medication used. The USPSTF found adequate evidence that the harms of bisphosphonates, the most commonly prescribed therapies, are no greater than small. Convincing evidence indicates that the harms of estrogen and selective estrogen receptor modulators are small to moderate. The USPSTF concluded that for women aged 65 years or older and younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors, there is moderate certainty that the net benefit of screening for osteoporosis by using DXA is at least moderate. The USPSTF concluded that, for men, evidence of the benefits of screening for osteoporosis is lacking and the balance of benefits and harms cannot be determined. (2011)

4 Abdominal Aortic Aneurysm. The USPSTF found good evidence that screening for AAA and surgical repair of large AAAs (5.5 cm or more) in men aged 65 to 75 who have ever smoked (current and former smokers) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms of screening and early treatment, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65 to 75 who have ever smoked outweigh the harms. The USPSTF found good evidence that screening for AAA in men aged 65 to 75 who have never smoked leads to decreased AAA-specific mortality. There is, however, a lower prevalence of large AAAs in men who have never smoked compared with men who have ever smoked; thus, the potential benefit from screening men who have never smoked is small. There is good evidence that screening and early treatment leads to important harms, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. The USPSTF concluded that the balance between the benefits and harms of screening for AAA is too close to make a general recommendation in this population. Because of the low prevalence of large AAAs in women, the number of AAA-related deaths that can be prevented by screening this population is small. There is good evidence that screening and early treatment result in important harms, including an increased number of surgeries with associated morbidity and mortality, and psychological harms. The USPSTF concluded that the harms of screening women for AAA outweigh the benefits. (2004)

5 Coronary Heart Disease. For asymptomatic adults at low risk for CHD events, the USPSTF found adequate evidence that the incremental information offered by resting or exercise ECG (beyond that obtained with conventional CHD risk factors) is highly unlikely to result in changes in risk stratification that would prompt interventions and ultimately reduce CHD-related events. The USPSTF based this conclusion on the epidemiology of CHD, the natural history of CHD, and established treatment strategies based on risk stratification. For asymptomatic adults at intermediate or high risk for CHD events, the USPSTF found inadequate evidence to determine the extent to which the incremental information offered by resting or exercise ECG (beyond that obtained with conventional CHD risk factors) results in changes in risk stratification that would prompt interventions and ultimately reduce CHD-related events. There is adequate evidence that screening asymptomatic adults with resting or exercise ECG leads to harms that are at least small, including unnecessary invasive procedures, overtreatment, and labeling. The USPSTF concluded with moderate certainty that the potential harms of screening for CHD with exercise or resting ECG equal or exceed the potential benefits in asymptomatic adults at low risk for CHD events. The USPSTF concluded that evidence is lacking and the balance of benefits and harms of screening for CHD with exercise or resting ECG in asymptomatic adults at intermediate or high risk for CHD events cannot be determined. For asymptomatic adults at low risk for CHD events, a resting or exercise ECG is unlikely to provide additional information about CHD risk beyond that obtained with conventional CHD risk factors (that is, Framingham risk factors) and result in changes in risk stratification that would prompt interventions and ultimately reduce CHD-related events. False-positive results may cause harms in low-risk asymptomatic adults. (2012)

There is insufficient evidence to determine the percentage of persons with an intermediate CHD risk who would be reclassified by screening with nontraditional risk factors other than hs-CRP and ABI. About 11% of men with an intermediate CHD risk would be reclassified into the high-risk category by hs-CRP screening, and about 12% of men would be reclassified into the low-risk category. National estimates of the number of women who would be reclassified by hs-CRP screening are not reliable because of small study samples. The available meta-analysis of individual data on ABI does not yield a clear picture on the proportion of intermediate-risk men who would be reclassified but does suggest that approximately 10% of women would be reclassified from intermediate to high risk for CHD. The evidence is insufficient to determine the magnitude of any reduction in CHD events and CHD-related deaths obtained by using nontraditional risk factors in CHD screening. This constitutes a critical gap in the evidence for benefit from screening. Little evidence is available to determine the harms of using nontraditional risk factors in CHD screening. Harms include lifelong use of medications without proof of benefit but with expense and potential side effects. Statins are the class of medication most commonly used; these medications have been demonstrated to be safe but are associated with the rare but serious side effect of rhabdomyolysis.1 Psychological and other harms may result from being put into a higher risk category for CHD events. The USPSTF concluded that the evidence is insufficient to determine the balance between benefits and harms of using nontraditional risk factors in screening for CHD risk. Although using hs-CRP and ABI to screen men and women with intermediate Framingham CHD risk would reclassify some into the low-risk group and others into the high-risk group, the evidence is insufficient to determine the ultimate effect on the occurrence of CHD events and CHD-related deaths. (2009)

6 Peripheral Arterial Disease. The USPSTF found no evidence that screening for and treatment of PAD in asymptomatic patients leads to clinically important benefits. It also reviewed the potential benefits of adding the ABI to the Framingham Risk Score (FRS) and found evidence that this results in some patient risk reclassification; however, how often the reclassification is appropriate or whether it results in improved clinical outcomes is not known. Determining the overall benefit of ABI testing requires not only evidence on appropriate risk reclassification but also evidence that this reclassification leads to treatments shown to improve clinical outcomes. One randomized trial found that aspirin did not reduce CVD events in patients with a low ABI (2). No studies assessed the effect of lipid-lowering therapy or other cardiovascular risk reduction interventions in patients with asymptomatic PAD and no known diagnosis of CVD or diabetes. The USPSTF found inadequate evidence that early treatment of screen-detected PAD leads to improvement in clinical outcomes. The USPSTF found no studies addressing the magnitude of harms of screening for PAD with the ABI; however, the direct harms to the patient of screening itself, beyond the time needed for the test, are probably minimal. Other harms resulting from testing may include false-positive results, exposure to gadolinium or contrast dye if magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is used to confirm diagnosis, anxiety, labeling, and opportunity costs. The USPSTF found inadequate evidence on the harms of early treatment of screen-detected PAD. One study showed that low-dose aspirin treatment in asymptomatic patients with a low ABI may increase bleeding. Additional harms associated with treatment include use of unnecessary medications (or higher doses) and their resulting adverse effects and discontinuation of medications known to be effective in patients with established coronary artery disease (CAD) if the patient is reclassified to a lower risk category on the basis of a normal ABI. The USPSTF concludes that the evidence on screening for PAD with the ABI in asymptomatic adults with no known diagnosis of CVD or diabetes is insufficient and that the balance of benefits and harms therefore cannot be determined. (2013)

7 Carotid Artery Stenosis. Good evidence indicates that in selected, high-risk trial participants with asymptomatic severe CAS, carotid endarterectomy by selected surgeons reduces the 5-year absolute incidence of all strokes or perioperative death by approximately 5%. These benefits would be less among asymptomatic people in the general population. For the general primary care population, the benefits are judged to be no greater than small. Good evidence indicates that both the testing strategy and the treatment with carotid endarterectomy can cause harms. A testing strategy that includes angiography will itself cause some strokes. A testing strategy that does not include angiography will cause some strokes by leading to carotid endarterectomy in people who do not have severe CAS. In excellent centers, carotid endarterectomy is associated with a 30-day stroke or mortality rate of about 3%; some areas have higher rates. These harms are judged to be no less than small. The USPSTF concluded that for individuals with asymptomatic CAS there is moderate certainty that the benefits of screening do not outweigh the harms. (2007)

8 COPD. Good evidence suggests that pharmacologic therapy prevents exacerbations (worsening of symptoms, requiring medical care) but does not affect hospitalizations or all-cause mortality among symptomatic individuals who have been smokers in the past ("ever smokers"), who are 40 years of age or older, and who have severe or very severe COPD (FEV1 90%) and small numbers needed to screen to identify 1 case of HCV infection ( ................
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