INTRODUCTION 

i.Overview 
This report is intended for primary care clinicians: physicians, nurses, 
nurse practitioners, physician assistants, other allied health 
professionals, and students. It provides recommendations for clinical 
practice on preventive interventions-screening tests, counseling 
interventions, immunizations, and chemoprophylactic regimens-for 
the prevention of more than 80 target conditions. The patients for 
whom these services are recommended include asymptomatic 
individuals of all age groups and risk categories. Thus, the subject 
matter is relevant to all of the major primary care specialties: family 
practice, internal medicine, obstetrics-gynecology, and pediatrics. The 
recommendations in each chapter reflect a standardized review of 
current scientific evidence and include a summary of published clinical 
research regarding the clinical effectiveness of each preventive 
service. 
 
Value of Prevention 
Clinicians have always intuitively understood the value of prevention. 
Faced daily with the difficult and often unsuccessful task of treating 
advanced stages of disease, primary care providers have long sought 
the opportunity to intervene early in the course of disease or even 
before disease develops. The benefits of incorporating prevention into 
medical practice have become increasingly apparent over the past 
30-40 years, as previously common and debilitating conditions have 
declined in incidence following the introduction of effective clinical 
preventive services. Infectious diseases such as poliomyelitis, which 
once occurred in regular epidemic waves (over 18,300 cases in 1954), 
have become rare in the U.S. as a result of childhood immunization.<1> 
Only three cases of paralytic poliomyelitis were reported in the U.S. in 
1993, and none was due to endemic wild virus. Before rubella vaccine 
became available, rubella epidemics occurred regularly in the U.S. 
every 6-9 years; a 1964 pandemic resulted in over 12 million rubella 
infections, 11,000 fetal losses and about 20,000 infants born with 
congenital rubella syndrome.<2,3> The incidence of rubella has 
decreased 99% since 1969, when the vaccine first became available.<4> 
Similar trends have occurred with diphtheria, pertussis, and other 
once-common childhood infectious diseases.<1> 

Preventive services for the early detection of disease have also been 
associated with substantial reductions in morbidity and mortality. Age-
adjusted mortality from stroke has decreased by more than 50% since 
1972, a trend attributed in part to earlier detection and treatment of 
hypertension.<5-7> Dramatic reductions in the incidence of invasive 
cervical cancer and in cervical cancer mortality have occurred 
following the implementation of screening programs using 
Papanicolaou testing to detect cervical dysplasia.<8> Children with 
metabolic disorders such as phenylketonuria and congenital 
hypothyroidism, who once suffered severe irreversible mental 
retardation, now usually retain normal cognitive function as a result of 
routine newborn screening and treatment.<9-16> 
Although immunizations and screening tests remain important 
preventive services, the most promising role for prevention in current 
medical practice may lie in changing the personal health behaviors of 
patients long before clinical disease develops. The importance of this 
aspect of clinical practice is evident from a growing literature linking 
some of the leading causes of death in the U.S., such as heart 
disease, cancer, cerebrovascular disease, chronic obstructive 
pulmonary disease, unintentional and intentional injuries, and human 
immunodeficiency virus infection,<17> to a handful of personal health 
behaviors. Smoking alone contributes to one out of every five deaths 
in the U.S., including 150,000 deaths annually from cancer, 100,000 
from coronary artery disease, 23,000 from cerebrovascular disease, 
and 85,000 from pulmonary diseases such as chronic obstructive 
pulmonary disease and pneumonia.<18> Failing to use safety belts and 
driving while intoxicated are major contributors to motor vehicle 
injuries, which accounted for 41,000 deaths in 1992.<17> Physical 
inactivity and dietary factors contribute to coronary atherosclerosis, 
cancer, diabetes, osteoporosis, and other common diseases.<19-22> 
High-risk sexual practices increase the risk of unintended pregnancy, 
sexually transmitted diseases (STDs), and acquired immunodeficiency 
syndrome.<23,24> Approximately half of all deaths occurring in the U.S. 
in 1990 may be attributed to external factors such as tobacco, alcohol, 
and illicit drug use, diet and activity patterns, motor vehicles, and 
sexual behavior, and are therefore potentially preventable by changes 
in personal health practices.<25> 
 
Barriers to Preventive Care Delivery 
Although sound clinical reasons exist for emphasizing prevention in 
medicine, studies have shown that clinicians often fail to provide 
recommended clinical preventive services.<26-32> This is due to a 
variety of factors, including inadequate reimbursement for preventive 
services, fragmentation of health care delivery, and insufficient time 
with patients to deliver the range of preventive services that are 
recommended.<33-35> Even when these barriers to implementation are 
accounted for, however, clinicians fail to perform preventive services 
as recommended,<28> suggesting that uncertainty among clinicians as 
to which services should be offered is a factor as well. 

Part of the uncertainty among clinicians derives from the fact that 
recommendations come from multiple sources, and these 
recommendations often differ. Recommendationsa relating to clinical 
preventive services are issued regularly by government health 
agencies and expert panels that they sponsor,<5,36-42> medical 
specialty organizations,<43-50> voluntary associations,<51-53> other 
professional and scientific organizations,<54,55> and individual 
experts.<56-59> 

A second major reason clinicians might be reluctant to perform 
preventive services is skepticism about their effectiveness. Whether 
performance of certain preventive interventions can significantly 
reduce morbidity or mortality from the target condition is often unclear. 
The relative effectiveness of different preventive services is also 
unclear, making it difficult for busy clinicians to decide which 
interventions are most important during a brief patient visit. A broader 
concern is that some maneuvers can ultimately result in more harm 
than good. While this concern applies to all clinical practices, it is 
especially important in relation to preventive services because the 
individuals who receive these interventions are often healthy. Minor 
complications or rare adverse effects that would be tolerated in the 
treatment of a severe illness take on greater importance in the 
asymptomatic population and require careful evaluation to determine 
whether benefits exceed risks. This is particularly relevant for 
screening tests, which benefit only the few individuals who have the 
disorder but expose all the individuals screened to the risk of adverse 
effects from the test. Moreover, because recommendations for 
preventive services such as routine screening often include a large 
proportion of the population, there are potentially important economic 
implications. 
 
Historical Perspective 
Uncertainties about the effectiveness of clinical preventive services 
raise questions about the value of the routine health examination of 
asymptomatic persons, in which a predetermined battery of tests and 
physical examination procedures are performed as part of a routine 
checkup. The annual physical examination of healthy persons was first 
proposed by the American Medical Association in 1922.<60> For many 
years after, it was common practice among health professionals to 
recommend routine physicals and comprehensive laboratory testing as 
effective preventive medicine. While routine visits with the primary 
care clinician are important, performing the same interventions on all 
patients and performing them annually are not the most clinically 
effective approaches to disease prevention. Rather, both the 
frequency and the content of the periodic health examination should 
reflect the unique health risks of the individual patient and the quality 
of the evidence that specific preventive services are clinically 
effective. This new approach to the periodic visit was endorsed by the 
American Medical Association in 1983 in a policy statement that 
withdrew support for a standard annual physical examination.<61> The 
individualized periodic health visit should emphasize evidence of 
clinical effectiveness, and thus increased attention has turned to the 
collection of reliable data on the effectiveness of specific preventive 
services. 

One of the first comprehensive efforts to examine these issues was 
undertaken by the Canadian government, which in 1976 convened the 
Canadian Task Force on the Periodic Health Examination (CTFPHE). 
This expert panel developed explicit criteria to judge the quality of 
evidence from published clinical research on clinical preventive 
services, and the panel used uniform decision rules to link the strength 
of recommendations for or against a given preventive service to the 
quality of the underlying evidence (see Appendix A). These ratings 
were intended to provide the clinician with a means of selecting those 
preventive services supported by the strongest evidence of 
effectiveness. Using this approach, the CTFPHE examined preventive 
services for 78 target conditions, releasing its recommendations in a 
monograph published in 1979.<62> In 1982, the CTFPHE reconvened 
and applied its methodology to new evidence as it became available, 
periodically publishing revised recommendations and evaluations of 
new topics. These were updated and compiled in 1994 in The 
Canadian Guide to Clinical Preventive Health Care.<63> 
A similar effort began in the U.S. in 1984 when the Public Health 
Service commissioned the U.S. Preventive Services Task Force 
(USPSTF). Like the Canadian panel, this 20-member non-Federal 
panel was charged with developing recommendations for clinicians on 
the appropriate use of preventive interventions, based on a systematic 
review of evidence of clinical effectiveness.<64> A methodology similar 
to that of the CTFPHE was adopted at the outset of the project. This 
enabled the U.S. and Canadian panels to collaborate in a binational 
effort to review evidence and develop recommendations on preventive 
services. The first USPSTF met regularly between 1984 and 1988 to 
develop comprehensive recommendations addressing preventive 
services. The panel members and their scientific support staff 
reviewed evidence and developed recommendations on preventive 
services for 60 topic areas affecting patients from infancy to old age, 
published in 1989 as the Guide to Clinical Preventive Services. 
 
The Second U.S. Preventive Services Task Force 
The USPSTF was reconstituted in 1990 to continue and update these 
scientific assessments.<65> Its charge has been to evaluate the 
effectiveness of clinical preventive services that were not previously 
examined; to reevaluate those that were examined and for which there 
is new scientific evidence, new technologies that merit consideration, 
or other reasons to revisit the published recommendations; and to 
produce this new edition of the Guide, with updated recommendations 
for the periodic health examination. In addition, a continuing mission of 
the USPSTF has been to define a research agenda by identifying 
significant gaps in the literature. The USPSTF has 10 members, 
comprising two family physicians, two internists, two pediatricians, two 
obstetrician-gynecologists, and two methodologists. Content experts 
from academic institutions and Federal agencies also joined the 
deliberations of the panel on an ad hoc basis. The USPSTF met 
quarterly between September 1990 and April 1994, with scientific 
support staff from the Office of Disease Prevention and Health 
Promotion, Public Health Service, U.S. Department of Health and 
Human Services, to analyze systematically scientific evidence 
pertaining to clinical preventive services that had been published 
since the first edition of the Guide. 

The USPSTF greatly expanded its collaboration with medical specialty 
organizations and Federal agencies, and it has continued its close 
cooperation with the CTFPHE. Designated liaisons from primary care 
medical specialty societies (American Academy of Family Physicians, 
American Academy of Pediatrics, American College of Obstetricians 
and Gynecologists, and American College of Physicians), the 
agencies of the Public Health Service, and the CTFPHE attended all 
of the USPSTF meetings, and their respective organizations reviewed 
all draft recommendations. The USPSTF and the CTFPHE, which has 
also recently updated its analyses of the scientific evidence and 
recommendations,<63> shared background papers and draft chapters 
throughout their updating processes to avoid unnecessary duplication 
of effort. Seventeen chapters in The Canadian Guide to Clinical 
Preventive Health Care<63> were based in part on background papers 
prepared for the USPSTF, and 21 chapters in this edition of the Guide 
are based in part on papers prepared for the CTFPHE. The USPSTF 
also collaborated with the American College of Physicians Clinical 
Efficacy Assessment Program (CEAP), which uses a similar evidence-
based methodology. A liaison from the USPSTF regularly attended 
CEAP meetings, and several chapter updates were based on reviews 
prepared for CEAP. 

Principal Findings of the U.S. Preventive Services Task Force 
The review of evidence for the second edition of the Guide to Clinical 
Preventive Services has produced several important findings. These 
can be summarized as follows: 

1. Interventions that address patients personal health practices are 
vitally important. Effective interventions that address personal health 
practices are likely to lead to substantial reductions in the incidence 
and severity of the leading causes of disease and disability in the U.S. 
Primary prevention as it relates to such risk factors as smoking, 
physical inactivity, poor nutrition, alcohol and other drug abuse, and 
inadequate attention to safety precautions holds greater promise for 
improving overall health than many secondary preventive measures 
such as routine screening for early disease.<25> Therefore, clinician 
counseling that leads to improved personal health practices may be 
more valuable to patients than conventional clinical activities such as 
diagnostic testing. In the past, the responsibility of the clinician was 
primarily to treat illnesses; the asymptomatic healthy individual did not 
need to see the doctor. In addition, personal health behaviors were 
often not viewed as a legitimate clinical issue. A patients use of 
safety belts would receive less attention from the clinician than the 
results of a complete blood count (CBC) or a routine chest radiograph. 
A careful review of the data, however, suggests that different priorities 
are in order. Motor vehicle injuries affect nearly 3.5 million persons 
each year in the U.S.;<66> they account for over 40,000 deaths each 
year.<67> Proper use of safety belts can prevent 40-60% of motor 
vehicle injuries and deaths.<68-70> In contrast, there is little evidence 
that performing routine CBCs or chest radiographs improves clinical 
outcome,<71,72> and these procedures are associated with increased 
health care expenditures. 

An important corollary of this finding is that clinicians must assist 
patients to assume greater responsibility for their own health. In the 
traditional doctor-patient relationship, the patient adopts a passive role 
and expects the doctor to assume control of the treatment plan. 
Whereas the clinician is often the key figure in the treatment of acute 
illnesses and injuries, the patient is the principal agent in primary 
prevention that addresses personal health practices. Therefore, one of 
the initial tasks of the clinician practicing primary prevention is shifting 
control to the patient. To achieve competence in the task of helping to 
empower patients and in counseling them to change health-related 
behaviors, many clinicians will need to develop new skills (see 
Chapter iv). 

2. The clinician and patient should share decision-making. Many 
preventive services involve important risks or costs that must be 
balanced against their possible benefits. Because not all patients 
weigh risks and benefits the same way, clinicians must fully inform 
patients about the potential consequences of proposed interventions, 
including the possibility of invasive follow-up procedures, tests, and 
treatments. Incorporating patient preferences is especially important 
when the balance of risks and benefits, and therefore the best 
decision for each patient, depends greatly on the values placed on 
possible outcomes (e.g., prolonged life vs. substantial morbidity from 
treatment). Where evidence suggested that patient values were critical 
to the balance of risks and benefits (e.g., screening for Down 
syndrome or neural tube defects, hormone prophylaxis in 
postmenopausal women), the USPSTF specifically recommended 
patient education and consideration of patient preferences in decision-
making rather than a uniform policy for all patients. Shared decision-
making also requires explicitly acknowledging areas of uncertainty. 
Patients must understand not only what is known, but also what is not 
yet known about the risks and benefits from an intervention, in order to 
make an informed decision. 

3. Clinicians should be selective in ordering tests and providing 
preventive services. Although certain screening tests, such as blood 
pressure measurement,<73-75> Papanicolaou smears,<8> and 
mammography,<76> can be highly effective in reducing morbidity and 
mortality, the USPSTF found that many others are of unproven 
effectiveness. Screening tests with inadequate specificity often 
produce large numbers of false-positive results, especially when 
performed routinely without regard to risk factors; these results might 
lead to unnecessary and potentially harmful diagnostic testing and 
treatment. Recognizing the cardinal importance of avoiding harm to 
asymptomatic patients (primum non nocere), the USPSTF 
recommended against a number of screening tests (e.g., serum tumor 
markers for the early detection of pancreatic or ovarian cancer) that 
had unproven benefit but likely downstream harms. Many tests that 
lack evidence that they improve clinical outcome, such as home 
uterine activity monitoring, have the additional disadvantage of being 
expensive, especially when performed on large numbers of persons in 
the population. In a few instances, the USPSTF found evidence that 
certain screening tests that have been widely used in the past (e.g.,  
routine chest x-ray to screen for lung cancer, dipstick urinalysis for 
asymptomatic bacteriuria) are ineffective. Although the USPSTF did 
not base its recommendations on evidence of cost-effectiveness (see 
Chapter v), judging health benefit based on scientific evidence 
provides a rational basis for directing resources toward effective 
services and away from ineffective services and from interventions for 
which the balance of benefits and risks is uncertain.<65> 

In addition to weighing evidence for effectiveness, selecting 
appropriate screening tests requires considering age, gender, and 
other individual risk factors of the patient in order to minimize adverse 
effects and unnecessary expenditures (see Chapters ii and iii). An 
appreciation of the risk profile of the patient is also necessary to set 
priorities for preventive interventions. The need for assessing 
individual risk underscores a time-honored principle of medical 
practice: the importance of a complete medical history and detailed 
discussion with patients regarding their personal health practices, 
focused on identifying risk factors for developing disease. 

4. Clinicians must take every opportunity to deliver preventive services, 
especially to persons with limited access to care. Those individuals at 
highest risk for many preventable causes of premature disease and 
disability, such as cervical cancer, tuberculosis, human 
immunodeficiency virus infection, and poor nutrition, are the same 
individuals least likely to receive adequate preventive services. 
Devising strategies to increase access to preventive services for such 
individuals is more likely to reduce morbidity and mortality from these 
conditions than performing preventive services more frequently on 
those who are already regular recipients of preventive care and who 
are often in better health. One important solution is to deliver 
preventive services at every visit, rather than exclusively during visits 
devoted entirely to prevention. While preventive checkups often 
provide more time for counseling and other preventive services, and 
although healthy individuals might be more receptive to such 
interventions than those who are sick, any visit provides an 
opportunity to practice prevention. In fact, some individuals may see 
clinicians only when they are ill or injured. The illness visit provides 
the only opportunity to reach individuals who, due to limited access to 
care, would be otherwise unlikely to receive preventive services. 

5. For some health problems, community-level interventions may be 
more effective than clinical preventive services. Important health 
problems that are likely to require broader-based interventions than 
can be offered in the clinical setting alone include youth and family 
violence, initiation of tobacco use, unintended pregnancy in 
adolescents, and certain unintentional injuries. Other types of 
interventions, such as school-based curricula,<77-81> community 
programs,<82-84> and regulatory and legislative initiatives,<85-87> might 
prove more effective for preventing morbidity and mortality from these 
conditions than will preventive services delivered in the clinical setting. 
There may, nevertheless, be an important role for clinicians as 
participants in community systems that address these types of health 
problems. Such a role might include becoming aware of existing 
community programs and encouraging patient participation and 
involvement; acting as a consultant for communities implementing 
programs or introducing legislation; and serving as an advocate to 
initiate and maintain effective community interventions. 
 
A Research Agenda in Preventive Medicine 
By reviewing comprehensively and critically the scientific evidence 
regarding clinical preventive services, the USPSTF identified 
important gaps in the literature and helped define targets for future 
clinical prevention research. Among the most important of these 
targets is more and better quality research evaluating the 
effectiveness of brief, directed counseling that can be delivered in the 
busy primary care practice setting. Given the importance of personal 
health practices, the scarcity of adequate evidence evaluating the 
effectiveness of brief counseling in the primary care setting is striking. 
The effectiveness of such counseling in reducing smoking and 
problem drinking is clear.<88-90> For many other behaviors, however, 
counseling has been tested and proven effective only in highly 
specialized settings (e.g., STD clinics<91-94>) or when delivered 
through multiple, lengthy visits with specially trained counselors (e.g., 
certain cholesterol-lowering interventions<95,96>). Whether the effects 
of these interventions can be reproduced by brief advice during the 
typical clinical encounter with a primary care provider is uncertain. 
Counseling to change some personal health practices (e.g., unsafe 
pedestrian behavior, drinking and driving) has received insufficient 
attention by researchers. Some personal health practices may not 
respond to brief clinician counseling in the context of routine health 
care. Therefore, research should also evaluate the effectiveness (and 
cost-effectiveness) of referring patients to allied health professionals 
with special counseling skills in their areas of expertise (e.g., 
dietitians, substance abuse counselors) and of using other modalities 
to educate patients in the primary care setting (e.g., videos, interactive 
software). 

For screening interventions, randomized controlled trials are powerful 
in resolving controversy about the benefits and risks. Many important 
questions will be answered by major ongoing screening trials such as 
the Prostate, Lung, Colorectal, Ovarian Cancer (PLCO) Screening 
Trial of the National Cancer Institute,<97> and by ongoing trials 
evaluating the clinical efficacy of treating common asymptomatic 
conditions detectable by screening, such as high cholesterol levels in 
the elderly and moderately elevated blood lead levels in children. For 
unproven screening interventions, finding ways to streamline 
randomized controlled trials so that they can be performed efficiently 
and cost-effectively is essential. 

Improving the Delivery of Clinical Preventive Services 
This report will help resolve some of the uncertainties among primary 
care clinicians about the effectiveness of preventive services, thus 
removing one barrier to the appropriate delivery of preventive care. 
The USPSTF did not, however, address other barriers to implementing 
clinical preventive services, such as insufficient reimbursement for 
counseling or other preventive interventions, provider uncertainty 
about how to deliver recommended services, lack of patient or 
provider interest in preventive services, and lack of 
organizational/system support to facilitate the delivery of clinical 
preventive services. Many of these barriers are addressed by Put 
Prevention into Practice, the Public Health Service prevention 
implementation program.<98> Programs such as Put Prevention into 
Practice can help ensure that prevention is delivered at every 
opportunity that  patients are seen. Other publications also provide 
useful information on the effective delivery of clinical preventive 
services.<99> The increasing formation of integrated health care 
systems (e.g., managed care organizations) may also create new 
opportunities for crafting better preventive practices. 

The USPSTF explored issues of prevention for a wide range of 
disease categories and for patients of all ages. The comprehensive 
and systematic approach to the review of evidence for each topic 
should provide clinicians with the means to compare the relative 
effectiveness of different preventive services and to determine, on the 
basis of scientific evidence, what is most likely to benefit their patients. 
Organizations using evidence-based methodologies to develop 
guidelines on clinical preventive services are finding broad agreement 
on a core set of preventive services of proven effectiveness that can 
be recommended to primary care providers and their patients.<63,100> 
Basing preventive health care decisions on the evidence of their 
effectiveness is an important step in the progress of disease 
prevention and health promotion in the U.S. 

The draft update of this chapter was prepared for the U.S. Preventive 
Services Task Force by Carolyn DiGuiseppi, MD, MPH. 
 
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