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## Complete Summary

#### GUIDELINE TITLE

Adult preventive services (ages 18 - 49).

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Adult preventive services (ages
18-49). Southfield (MI): Michigan Quality Improvement Consortium; 2006
Sep. 1 p.

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Preventable diseases and conditions, such as

-   Overweight/obesity

-   Hypertension

-   Dyslipidemia

-   Diabetes mellitus

-   Chlamydia infection

-   Colorectal cancer

-   Glaucoma

-   Cervical cancer

-   Breast cancer

-   Tetanus

-   Diphtheria

-   Pertussis

-   Human papilloma virus

-   Influenza

#### GUIDELINE CATEGORY

Prevention\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Health Plans\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To achieve significant, measurable improvements in the management of
    adult preventive services (ages 18 to 49) through the development
    and implementation of common evidence-based clinical practice
    guidelines

-   To design concise guidelines that are focused on key management
    components of adult preventive services (ages 18 to 49) to improve
    outcomes

#### TARGET POPULATION

-   Adult patients ages 18 to 39 years

-   Adult patients ages 40 to 49 years

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening/Prevention**

1.  Health maintenance exam including height and weight; risk evaluation
    and counseling (e.g., nutrition, physical activity, tobacco use,
    sexual health); safety assessment (e.g., domestic violence, seat
    belts, firearms); behavioral assessment (e.g., depression, suicide
    threats, alcohol/drug use)

2.  Blood pressure measurement

3.  Screening for the following diseases/conditions:

    -   Dyslipidemia

    -   Diabetes mellitus

    -   Chlamydia infection

    -   Colorectal cancer

    -   Glaucoma

    -   Cervical cancer

    -   Breast cancer

4.  Immunizations (Tetanus diphtheria acellular
    pertussis/Tetanus-diphtheria \[TDaP/Td\], human papilloma virus
    \[HPV\], influenza)

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Michigan Quality Improvement Consortium (MQIC) project leader
conducts a search of current literature in support of the guideline
topic. Computer database searches are used to identify published studies
and existing protocols and/or clinical practice guidelines on the
selected topic. A database such as MEDLINE and two to three other
databases are used.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence for the Most Significant Recommendations**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Using the health plan guideline summaries and information obtained from
the literature search, the Michigan Quality Improvement Consortium
(MQIC) director and/or project leader prepare a draft guideline for
review by the MQIC Medical Directors.

The draft guideline and health plan guideline summaries are distributed
to the MQIC Medical Directors for review and discussion at their next
committee meeting.

The review/revision cycle may be conducted over several meetings before
consensus is reached. Each version of the draft guideline is distributed
to the MQIC Medical Directors, Measurement, and Implementation Committee
members for review and comments. All feedback received is distributed to
the entire membership.

Once the MQIC Medical Directors achieve consensus on the draft
guideline, it is considered approved for external distribution to
practitioners with review and comments requested.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Once the Michigan Quality Improvement Consortium (MQIC) Medical
Directors achieve consensus on the draft guideline, it is considered
approved for external distribution to practitioners with review and
comments requested.

The MQIC director also forwards the approved guideline draft to
presidents of the appropriate state medical specialty societies for
their input. All feedback received from external reviews is presented
for discussion at the next MQIC Medical Directors Committee meeting. In
addition, physicians are invited to attend the committee meeting to
present their comments.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary. The
recommendations that follow are based on the previous version of the
guideline.

The level of evidence grades (A-D) are provided for the most significant
recommendations and are defined at the end of the \"Major
Recommendations\" field.

**Health Assessment Screening, History, and Counseling**

*Ages 18 to 49 Years*

One health maintenance exam (HME) every 1 to 5 years according to risk
status **\[D\]**. Each HME should include:

-   Height, weight, and body mass index (BMI)

-   Risk Evaluation & Counseling (nutrition, overweight/obesity,
    physical activity, dental health, tobacco use **\[A\]**,
    immunizations, human immunodeficiency virus (HIV) prevention
    **\[B\]**, sexually transmitted diseases prevention **\[B\]** and
    sexual health, sexual abuse, preconception counseling for all women
    of reproductive age **\[B\]**, polypharmacy including
    over-the-counter and herbal preparations when appropriate, sun
    exposure)

-   Safety (domestic violence, seat belts **\[B\]**, helmets, firearms,
    smoke and carbon monoxide detectors)

-   Behavioral Assessment (depression, suicide threats, alcohol/drug
    use, anxiety, stress reduction, coping skills)

**Blood Pressure Measurement \[A\]**

*Ages 18 to 49 Years*

At every office visit and, at minimum, every 2 years. If blood pressure
(BP) 120/80 or higher and/or presence of risk factors, more frequent
monitoring is recommended.

**Cholesterol and Lipid Screening \[B\]**

*Ages 18 to 49 Years*

Measure a complete fasting lipoprotein profile (i.e., total cholesterol,
low-density lipoprotein cholesterol \[LDL-C\], high-density lipoprotein
cholesterol \[HDL-C\], and triglycerides) every 5 years if initial test
is normal in low-risk adults. If multiple risk factors are present, more
frequent measurements are recommended.

**Diabetes Mellitus Screening \[C\]**

*Ages 18 to 39 Years*

No requirement unless high risk (e.g., family history of diabetes,
obesity, hypertension, dyslipidemia, cardiovascular disease, African
Americans, Native Americans, and Hispanics)

*Ages 40 to 49 Years*

Fasting plasma glucose (FPG) every 3 years (especially if BMI \>25) and
at clinical discretion. Regular screening over age 45.

**Chlamydia Screening \[B\]**

*Ages 18 to 49 Years*

Recommended for all sexually active women age 25 and younger, and
sexually active women age 26 and older if high risk (i.e., new or
multiple sexual partners, history of sexually transmitted diseases, not
using condoms consistently or correctly)

**Colorectal Cancer Screening \[B\] for Average Risk Adults**

*Ages 18 to 49 Years*

No requirement unless high risk (e.g., family history, history of
colorectal polyps, chronic inflammatory bowel disease)

**Glaucoma Screening \[C\]**

*Ages 18 to 39 Years*

No requirement unless high risk (e.g., increased intraocular pressure,
family history, African Americans, people who have diabetes, myopia,
regular/long-term steroid use, previous eye injury)

*Ages 40 to 49 Years*

Begin screening high risk patients annually at age 45

**Cervical Cancer Screening \[A\] Pap Smear**

*Ages 18 to 49 Years*

At least every 3 years, more frequently if high risk (i.e., history of
abnormal Pap results, sexually transmitted diseases or HIV; sexual
activity before age 18 or multiple partners; vaginal spotting or
bleeding between periods, after intercourse or after menopause; tobacco
use). (Consider discontinuation for patients with surgical removal of
cervix for benign conditions).

**Mammography \[C\]**

*Ages 18 to 39 Years*

No requirement, unless high risk

*Ages 40 to 49 Years*

Every 1 to 2 years

**Clinical Breast Exam \[C\]**

*Ages 18 to 39 Years*

Every 3 years

*Ages 40 to 49 Years*

Every 1 to 2 Years

**Immunizations**

**Tetanus Diphtheria Acellular Pertussis/Tetanus-diphtheria (TDaP/Td)
\[A\]**

*Ages 18 to 49 Years*

TDaP once after age 11, then Td every 10 years

**Human Papilloma Virus (HPV)**

*Ages 18 to 39 Years*

All females 26 years and younger should have full three vaccine series
if not previously completed.

**Influenza \[B\]**

*Ages 18 to 49 Years*

Every year if high risk; optional for those who wish to avoid getting
the flu

**Definitions**:

**Levels of Evidence for the Most Significant Recommendation**

A.  Randomized controlled trials

B.  Controlled trials, no randomization

C.  Observational studies

D.  Opinion of expert panel

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is provided for the most significant
recommendations (see \"Major Recommendations\" field).

This guideline is based on several sources, including: *The Guide to
Clinical Preventive Services 2005, Recommendations of the U.S.
Preventive Services Task Force*
([www.preventiveservices.ahrq.gov](http://www.preventiveservices.ahrq.gov/)),
and the *Advisory Committee on Immunization Practices (ACIP) 2006
Immunization Recommendations* ([www.cdc.gov](http://www.cdc.gov/)).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Through a collaborative approach to developing and implementing common
clinical practice guidelines and performance measures for adult
preventive services (ages 18 to 49), Michigan health plans will achieve
consistent delivery of evidence-based services and better health
outcomes. This approach also will augment the practice environment for
physicians by reducing the administrative burdens imposed by compliance
with diverse health plan guidelines and associated requirements.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline lists core management steps. Individual patient
considerations and advances in medical science may supersede or modify
these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

When consensus is reached on a final version of the guideline, a
statewide mailing of the approved guideline is completed. The guideline
is distributed to physicians in the following medical specialties:

-   Family Practice

-   General Practice

-   Internal Medicine

-   Other Specialists for which the guideline is applicable (e.g.,
    endocrinologists, allergists, pediatricians, cardiologists)

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Michigan Quality Improvement Consortium. Adult preventive services (ages
18-49). Southfield (MI): Michigan Quality Improvement Consortium; 2006
Sep. 1 p.

#### ADAPTATION

This guideline is based on several sources, including: *The Guide to
Clinical Preventive Services 2005, Recommendations of the U.S.
Preventive Services Task Force*
([www.preventiveservices.ahrq.gov](http://www.preventiveservices.ahrq.gov/)),
and the *Advisory Committee on Immunization Practices (ACIP) 2006
Immunization Recommendations* ([www.cdc.gov](http://www.cdc.gov/)).

#### DATE RELEASED

2005 Jul (revised 2006 Sep)

#### GUIDELINE DEVELOPER(S)

Michigan Quality Improvement Consortium - Professional Association

#### SOURCE(S) OF FUNDING

Michigan Quality Improvement Consortium

#### GUIDELINE COMMITTEE

Michigan Quality Improvement Consortium Medical Director\'s Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Physician representatives from participating Michigan Quality
Improvement Consortium health plans, Michigan State Medical Society,
Michigan Osteopathic Association, Michigan Association of Health Plans,
Michigan Department of Community Health, and Michigan Peer Review
Organization

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

#### GUIDELINE AVAILABILITY

Electronic copies of the updated guideline: Available in Portable
Document Format (PDF) from the [Michigan Quality Improvement Consortium
Web site](http://www.mqic.org/guid.htm).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on November 28, 2005. The updated
information was verified by the guideline developer on December 19,
2005. This NGC summary was updated by ECRI on October 13, 2006. The
updated information was verified by the guideline developer on November
3, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
reproduced with the citation developed by the Michigan Quality
Improvement Consortium.

### DISCLAIMER

#### NGC DISCLAIMER

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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008