# Presentation: 175702

## Encouraging Preventive ScreeningsNew “News” from the U.S. Preventive Service Task Force

*Therese Miller, DrPH*
*Mary Barton, MD, MPP*
*Claire Kendrick, MSEd *
*Iris Mabry, MD, MPH*
*Janice Genevro, PhD*
* *

## AHRQ Mission Statement

*       **To improve the quality, safety, efficiency, and effectiveness of health care for all Americans*

**Notes:**
The mission of the agency is... 

## Congressional Mandate

**Under Title IX of the Public Health Service Act, (42 U.S.C. 299-299c-7 as amended by Public Law 106-129 (1999):**
**ESTABLISHMENT AND PURPOSE*****. – ***
***The Director may periodically convene a Preventive Services Task Force to be composed of individuals with appropriate expertise.  Such a task force shall review the scientific evidence related to the effectiveness, appropriateness, and cost-effectiveness of clinical preventive services for the purpose of developing recommendations for the health care community, and updating previous clinical preventive recommendations.*****  **

**Notes:**
The federal government is mandated to periodically convene the task force
Next

## History of the USPSTF & AHRQ

**1976 - Canadian Task Force on PHE**
**1984 - USPSTF established by PHS**
**1998 - 3rd USPSTF reconvened by AHRQ**
**2001 - Task Force made a standing body**

**Notes:**
Where did the task force come from?
(Read above) PHE = periodic health exam
next

## Current USPSTF Members as of January 2006

**Bruce N. (Ned) Calonge, M.D., M.P.H. (Chair)**
**Diana B. Petitti, M.D., M.P.H. (Vice Chair)**
**Thomas G. DeWitt, M.D.****	****	****   Lucy N. Marion, Ph.D., R.N.**
**Leon Gordis, M.D., M.P.H., Dr.P.H.****	****  Virginia A. Moyer, M.D., M.P.H.**
**Kimberly D. Gregory, M.D., M.P.H.****	****  Judith K. Ockene, Ph.D., M.Ed.**
**Russell Harris, M.D., M.P.H. ****	****	****  George F. Sawaya, M.D.**
**George Isham, M.D., M.P.H.****	****	****  Albert L. Siu, M.D., M.S.P.H.****	**
**Michael LeFevre, M.D., M.S.P.H****.****	****  Steven M. Teutsch, M.D., M.P.H.**
**Carol J. Loveland-Cherry, ****Ph.D., R.N.****	****  Barbara Yawn, M.D., M.Sc.**

## Task Force Activities

- Provide **evidence-based** scientific reviews of preventive health services for use in **primary healthcare delivery settings**
-  Age- and risk-factor specific recommendations for routine practice
- Recommendations include:
- Screening tests
- Counseling
- Preventive medications`

## The U.S. Preventive Services Task Force (USPSTF)
recommends against routine referral for genetic
counseling or routine breast cancer susceptibility
gene (BRCA) testing for women whose family
history is not associated with an increased risk for
deleterious mutations in breast cancer
susceptibility gene 1 (BRCA1) or breast cancer
susceptibility gene 2 (BRCA2). 

Rating: D Recommendation

**recommends against routine referral for genetic**
**counseling or routine breast cancer susceptibility**
**gene (*****BRCA*****) testing for women whose family**
**history is not associated with an increased risk for**
**deleterious mutations in breast cancer**
**susceptibility gene 1 (*****BRCA1*****) or breast cancer**
**susceptibility gene 2 (*****BRCA2*****).**
**Rating: **_[D Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#drec)_

**What the USPSTF Says...**

## Rationale: The USPSTF found fair evidence that women without certain
specific family history patterns, termed here "increased risk family history" (go
to Clinical Considerations for a definition), have a low risk for developing
breast or ovarian cancer associated with BRCA1 or BRCA2 mutations. Thus,
any benefit to routine screening of these women for BRCA1 or BRCA2
mutations, or routine referral for genetic counseling, would be small or zero.

The USPSTF found fair evidence regarding important adverse ethical, legal,
and social consequences that could result from routine referral and testing of
these women. Interventions such as prophylactic surgery, chemoprevention,
or intensive screening have known harms. The USPSTF estimated that the
magnitude of these potential harms is small or greater. The USPSTF
concluded that the potential harms of routine referral for genetic counseling or
BRCA testing in these women outweigh the benefits. 

- specific family history patterns, termed here "increased risk family history" (go
- to _[Clinical Considerations](http://www.ahrq.gov/clinic/uspstf05/brcagen/brcagenrs.htm#clinical)__ for a definition), have a low risk for developing_
- breast or ovarian cancer associated with *BRCA1* or *BRCA2* mutations. Thus,
- any benefit to routine screening of these women for *BRCA1* or *BRCA2*
- mutations, or routine referral for genetic counseling, would be small or zero.
- The USPSTF found fair evidence regarding important adverse ethical, legal,
- and social consequences that could result from routine referral and testing of
- these women. Interventions such as prophylactic surgery, chemoprevention,
- or intensive screening have known harms. The USPSTF estimated that the
- magnitude of these potential harms is small or greater. The USPSTF
- concluded that the potential harms of routine referral for genetic counseling or
- BRCA testing in these women outweigh the benefits.

**What the USPSTF Says...**

## What Clinicians Want to Hear...

**Do it**
**Don’t do it**
**We don’t know**

## What the USPSTF Grades Mean

**What the USPSTF Grades Mean**

| Examples |  |
| --- | --- |
|  |  |
| Grade | Grade Definitions |
| A | The USPSTF recommends the service. There is high certainty that the net benefit is substantial. |
|  |  |
| D | The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. |

## USPSTF Levels of Certainty Regarding Net Benefit

**Definition:****	**
**The U.S. Preventive Services Task Force defines**
**certainty as “likelihood that the USPSTF**
**assessment of the net benefit of a preventive service**
**is correct”. The net benefit is defined as benefit **
**minus harm of the preventive service as implemented **
**In a general, primary care population.  The USPSTF**
**assigns a certainty level based on the nature of the**
**overall evidence available to assess the net benefit of**
**a preventive service.**

**Notes:**

Not changing:
Magnitude of net benefit refers to the USPSTF’s estimate of the magnitude of benefits “minus” the magnitude of harms that would result from implementing the proposed preventive service. 

## Suggestions for Practice

**Suggestions for Practice**

| Grade |  |
| --- | --- |
| A | Offer/provide this service. |
| B | Offer/provide this service.  |
| C | Offer/provide this service only if there are other considerations in support of the offering/providing the service in an individual patient. |
| D | Discourage the use of this service.  |
| I
Stmt | Read “Clinical Considerations” section of USPSTF Recommendation Statement.  If offered, patients should understand the uncertainty about the balance of benefits and harms. |

## Screening for Chlamydia Infection

| Population | Non-Pregnant Women |  |  | Pregnant Women |  |  | Men |
| --- | --- | --- | --- | --- | --- | --- | --- |
|  | Younger than 25 yrs | Older than 25 yrs |  | Younger than 25 yrs | Older than 25 yrs |  |  |
|  | includes adolescents | Low Risk | High Risk | includes adolescents | Low Risk | High Risk |  |
| Rec | A
Screen if 
Sexually Active | C | A
Screen if Sexually Active | B
Screen | C | B
Screen | No recommendation due to insufficient evidence.* |

**Screening for Chlamydia Infection**

| Risk Factors  | History of: previous Chlamydia infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work.
Prevalence is higher in African-American women, Latinas, military recruits, patients at public STI clinics, and incarcerated populations. |  |  |
| --- | --- | --- | --- |
| Screening Tests | Nucleic acid amplification tests (NAATs) can identify Chlamydia infection in asymptomatic women (non-pregnant and pregnant) and asymptomatic men.
NAATs have high specificity and sensitivity and can be used with urine and vaginal swabs.  |  |  |
| Screening Intervals | Non-Pregnant Women | Pregnant Women |  |
|  | The optimal interval for screening is not known.
The CDC recommends that women at increased risk be screened at least annually.1 | For patients at risk: Screen at the first prenatal visit.
For patients at continuing risk, or who are newly at risk: Screen in the 3rd trimester. |  |
| Treatment | The Centers for Disease Control and Prevention have outlined appropriate treatment.
 http://www.cdc.gov/STD/treatment/4-2002TG.htm#Chlamydia 
Test and/or treat partners of patients treated for Chlamydia infection. |  |  |

**Notes:**
Say one page also includes additional information on I statements and refers clinicians to the rationale and full recommendation statement for more information.

## Resources for Primary Care Clinicians

www.preventiveservices.ahrq.gov

**www.preventiveservices.ahrq.gov**

## United Health  Foundation to distribute 430,000 to primary care clinicians
Partnership with CDC (ACIP)

**Partnership with CDC (ACIP)**

**The Guide to Clinical Preventive Services 2006**

**Notes:**
Advisory Council immunization programs

## Slide 16

## Released YESTERDAY 

Search USPSTF recommendations by age, sex and risk factors 

Available as a web-based tool or can be downloaded to your PDA

www.epss.ahrq.gov 

- Search USPSTF recommendations by age, sex and risk factors
- Available as a web-based tool or can be downloaded to your PDA
- _[www.epss.ahrq.gov](http://www.epss.ahrq.gov/)__ _

***e*****PSS - Electronic **
**Preventive Services Selector Tool**

**Notes:**
Now I would like to talk to you about some of the resources that we provide for our different audiences. 

As Sec Leavitt mentioned in his key note address, today we released the electronic Preventive Services Selector tool. The ePSS is a quick hands-on tool designed to help primary care clinicians identify the screening, counseling, and preventive medication services that are appropriate for their patients. It is based on current recommendations of the U.S. Preventive Services Task Force and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors. The ePSS is available as a web-based tool and can also be downloaded to PDA devices. 

This tool can be accessed at www.epss.ahrq.gov. There is a bookmark in your bag with this web address on it. HOLD UP BOOKMARK. 

## Slide 18

**Notes:**
This is a screen shot of the Search for Recommendation page on the web based version of the ePSS. 

On this page, all fields are optional.

For a targeted search based on age, sex and other factors, simply input your patients information into the fields and click show recommendations 

## Slide 19

**Notes:**
This is a screen shot of the PDA version of the tool as it would appear on a Pocket PC device. It can also be downloaded to Palm Devices. You can see that is has all of the same search capabilities as the web-based tool. 

## Encouraging Preventive Screenings

**Notes:**
We have cartoons too