Practice Guidelines

Partnership for Prevention Ranks Preventive Services



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Am Fam Physician. 2006 Nov 15;74(10):1787.

Physicians must address chronic conditions, acute illness, and preventive care with their patients during brief office visits. Prioritizing health care services can help physicians identify those that are most important to discuss with patients. The Partnership for Prevention conducted a study, sponsored by the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, to accurately rank 25 preventive health care services. These rankings represent the most valuable preventive services and should be used to help physicians prioritize which services to emphasize with patients. The full results of the study were published in the July 2006 issue of the American Journal of Preventive Medicine and are available at http://www.prevent.org/ncpp.

Study Methods

The National Commission on Prevention Priorities (NCPP), made up of decision makers from health insurers, employers, academia, and government groups, was convened to update the Partnership for Prevention's 2001 ranking of clinical preventive services, including immunizations, screening tests, counseling, and preventive medicine. The NCPP used recommendations from the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices through 2004, improved methods, and updated data and evidence to create the new list. The rankings are based on health impact (i.e., clinically preventable burden) and on cost-effectiveness (Table 1). Clinically preventable burden was defined as the disease, injury, and premature death that would be prevented if the service were delivered at recommended intervals to a U.S. birth cohort over the years of life that the service is available. Cost-effectiveness was defined as the average net cost per quality-adjusted life year gained by offering the service at recommended intervals to a U.S. birth cohort over the recommended age range.

TABLE 1

Ranking of Effective Clinical Preventive Services

Service Description Scores*

Clinically preventable burden

Cost-effectiveness

Total

Aspirin chemo-prophylaxis

To prevent cardiovascular events, discuss daily aspirin use with men older than 40 years, women older than 50 years, and others at increased risk of heart disease.

5

5

10

Childhood immunizationseries

Immunize children with diphtheria, tetanus, pertussis; measles, mumps, rubella; inactivated polio virus;Haemophilus influenzae type b; hepatitis B; varicella, pneumococcal conjugate; and influenza vaccines.

5

5

10

Tobacco-use screening and brief intervention

Screen adults for tobacco use, provide brief counseling, and offer pharmacotherapy.

5

5

10

Colorectal cancer screening

Routinely screen adults 50 years and older with fecal occult blood testing, sigmoidoscopy, or colonoscopy.

4

4

8

Hypertension screening

Routinely measure blood pressure in adults, and treat with antihypertensive medication to prevent cardiovascular disease.

5

3

8

Influenza immunization (adults)

Immunize adults 50 years and older against influenza annually.

4

4

8

Pneumococcal immunization (adults)

Immunize adults 65 years and older against pneumococcal disease (one dose is adequate for most persons in this population).

5

8

Problem drinking screening and brief counseling

Routinely screen adults for alcohol use that places them at increased risk, and provide brief counseling with follow-up.

4

8

Vision screening (adults)

Routinely screen adults 65 years and older for visual acuity with the Snellen chart.

3

5

8

Cervical cancer screening

Within three years of onset of sexual activity or at 21 years of age, routinely screen with cervical cytology women who are sexually active and have a cervix.

4

3

7

Cholesterol screening

Routinely screen men 35 years and older and women 45 years and older for lipid disorders, and treat with lipid-lowering drugs to prevent cardiovascular disease.

7

Breast cancer screening

Routinely screen women 50 years and older with mammography alone or with clinical breast examination, and discuss screening with women 40 to 49 years of age to determine the age at which screening should be initiated.

4

2

6

Chlamydia screening

Routinely screen sexually active women younger than 25 years for chlamydia.

2

4

6

Calcium chemoprophylaxis

Counsel adolescent and adult women to use calcium supplements to prevent fractures.

6

Vision screening (children)

Routinely screen children younger than five years for amblyopia, strabismus, and visual acuity.

2

6

Folic acid chemoprophylaxis

Routinely counsel women of childbearing age on the use of folic acid supplements to prevent birth defects.

2

3

5

Obesity screening

Routinely screen adults for obesity, and offer patients who are obese high-intensity counseling about diet, exercise, or both combined with behavioral interventions for at least one year.

3

2

5

Depression screening

Screen adults for depression in clinical practices with systems in place to ensure accurate diagnosis, treatment, and follow-up.

3

1

4

Hearing screening

Screen adults 65 years and older for hearing impairment, and make referrals to subspecialists.

2

2

4

Injury prevention counseling

Assess the safety practices of parents with children younger than five years, and provide them with safety counseling (e.g., child safety seats, window and stair guards, pool fence, poison control, hot water temperature, bicycle helmets).

1

4

Osteoporosis screening

Routinely screen all women 65 years and older and women 60 years and older who are at increased risk for osteoporosis, and discuss the benefits and harms of treatment options.

2

2

4

Cholesterol screening (high risk)

Routinely screen men 20 to 35 years of age and women 20 to 45 years of age for lipid disorders if they have other risk factors for coronary heart disease, and treat with lipid-lowering drugs to prevent cardiovascular disease.

1

2

Diabetes screening

Screen adults with high cholesterol levels or hypertension for diabetes, and treat with a goal of lowering blood pressure and cholesterol levels to below conventional target values.

1

1

2

Diet counseling

Offer intensive behavioral dietary counseling to adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.

1

1

2

Tetanus-diphtheria booster

Immunize adults every 10 years.

1

1

2


note:Services in bold are those with high scores (6 or more) and low national utilization rates (50 percent or less). See Table 2 for data on additional quality-adjusted life years gained if utilization were increased to 90 percent.

*—Services that produce the most health benefits received the highest clinically preventable burden score of 5. Services that are most cost-effective received the highest cost-effectiveness score of 5. The two scores were then added to give each service a total score between 2 and 10.

†—Clinically preventable burden is the disease, injury, and premature death that would be prevented if the service were delivered at recommended intervals to a U.S. birth cohort over the years of life that the service is available.

‡—Cost-effectiveness is the average net cost per quality-adjusted life year gained by offering the service at recommended intervals to a U.S. birth cohort over the recommended age range.

§—Sensitivity analysis revealed that a change of a score of 2 or more is possible.

Adapted with permission from Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Soldberg LI. Priorities among effective clinical preventive services. Am J Prev Med 2006;31:56.

TABLE 1   Ranking of Effective Clinical Preventive Services

View Table

TABLE 1

Ranking of Effective Clinical Preventive Services

Service Description Scores*

Clinically preventable burden

Cost-effectiveness

Total

Aspirin chemo-prophylaxis

To prevent cardiovascular events, discuss daily aspirin use with men older than 40 years, women older than 50 years, and others at increased risk of heart disease.

5

5

10

Childhood immunizationseries

Immunize children with diphtheria, tetanus, pertussis; measles, mumps, rubella; inactivated polio virus;Haemophilus influenzae type b; hepatitis B; varicella, pneumococcal conjugate; and influenza vaccines.

5

5

10

Tobacco-use screening and brief intervention

Screen adults for tobacco use, provide brief counseling, and offer pharmacotherapy.

5

5

10

Colorectal cancer screening

Routinely screen adults 50 years and older with fecal occult blood testing, sigmoidoscopy, or colonoscopy.

4

4

8

Hypertension screening

Routinely measure blood pressure in adults, and treat with antihypertensive medication to prevent cardiovascular disease.

5

3

8

Influenza immunization (adults)

Immunize adults 50 years and older against influenza annually.

4

4

8

Pneumococcal immunization (adults)

Immunize adults 65 years and older against pneumococcal disease (one dose is adequate for most persons in this population).

5

8

Problem drinking screening and brief counseling

Routinely screen adults for alcohol use that places them at increased risk, and provide brief counseling with follow-up.

4

8

Vision screening (adults)

Routinely screen adults 65 years and older for visual acuity with the Snellen chart.

3

5

8

Cervical cancer screening

Within three years of onset of sexual activity or at 21 years of age, routinely screen with cervical cytology women who are sexually active and have a cervix.

4

3

7

Cholesterol screening

Routinely screen men 35 years and older and women 45 years and older for lipid disorders, and treat with lipid-lowering drugs to prevent cardiovascular disease.

7

Breast cancer screening

Routinely screen women 50 years and older with mammography alone or with clinical breast examination, and discuss screening with women 40 to 49 years of age to determine the age at which screening should be initiated.

4

2

6

Chlamydia screening

Routinely screen sexually active women younger than 25 years for chlamydia.

2

4

6

Calcium chemoprophylaxis

Counsel adolescent and adult women to use calcium supplements to prevent fractures.

6

Vision screening (children)

Routinely screen children younger than five years for amblyopia, strabismus, and visual acuity.

2

6

Folic acid chemoprophylaxis

Routinely counsel women of childbearing age on the use of folic acid supplements to prevent birth defects.

2

3

5

Obesity screening

Routinely screen adults for obesity, and offer patients who are obese high-intensity counseling about diet, exercise, or both combined with behavioral interventions for at least one year.

3

2

5

Depression screening

Screen adults for depression in clinical practices with systems in place to ensure accurate diagnosis, treatment, and follow-up.

3

1

4

Hearing screening

Screen adults 65 years and older for hearing impairment, and make referrals to subspecialists.

2

2

4

Injury prevention counseling

Assess the safety practices of parents with children younger than five years, and provide them with safety counseling (e.g., child safety seats, window and stair guards, pool fence, poison control, hot water temperature, bicycle helmets).

1

4

Osteoporosis screening

Routinely screen all women 65 years and older and women 60 years and older who are at increased risk for osteoporosis, and discuss the benefits and harms of treatment options.

2

2

4

Cholesterol screening (high risk)

Routinely screen men 20 to 35 years of age and women 20 to 45 years of age for lipid disorders if they have other risk factors for coronary heart disease, and treat with lipid-lowering drugs to prevent cardiovascular disease.

1

2

Diabetes screening

Screen adults with high cholesterol levels or hypertension for diabetes, and treat with a goal of lowering blood pressure and cholesterol levels to below conventional target values.

1

1

2

Diet counseling

Offer intensive behavioral dietary counseling to adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.

1

1

2

Tetanus-diphtheria booster

Immunize adults every 10 years.

1

1

2


note:Services in bold are those with high scores (6 or more) and low national utilization rates (50 percent or less). See Table 2 for data on additional quality-adjusted life years gained if utilization were increased to 90 percent.

*—Services that produce the most health benefits received the highest clinically preventable burden score of 5. Services that are most cost-effective received the highest cost-effectiveness score of 5. The two scores were then added to give each service a total score between 2 and 10.

†—Clinically preventable burden is the disease, injury, and premature death that would be prevented if the service were delivered at recommended intervals to a U.S. birth cohort over the years of life that the service is available.

‡—Cost-effectiveness is the average net cost per quality-adjusted life year gained by offering the service at recommended intervals to a U.S. birth cohort over the recommended age range.

§—Sensitivity analysis revealed that a change of a score of 2 or more is possible.

Adapted with permission from Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Soldberg LI. Priorities among effective clinical preventive services. Am J Prev Med 2006;31:56.

Results

Discussing daily aspirin use with high-risk adults, immunizing children, and screening for tobacco use (with a brief intervention in patients who smoke) received the highest score of 10, making them the most beneficial and cost-effective services on the list. High-ranking services (score of 6 or more) with low utilization rates (50 percent or less) included tobacco-use screening and brief intervention, colorectal screening in patients 50 years and older, pneumococcal immunization in patients 65 years and older, and chlamydia screening in young women.

Table 2 provides data on the additional quality-adjusted life years that would be saved if the utilization of these and other services was increased to 90 percent. The authors of the study encourage physicians to use the ranking when deciding what to emphasize during office visits and to improve the delivery of underutilized services that have proven benefits.

TABLE 2

Additional Quality-Adjusted Life Years Saved if Current Utilization of Beneficial Preventive Care Services Increased

Service Current national utilization (%) Additional quality-adjusted life years saved at 90 percent utilization*

Tobacco-use screening and brief intervention

35

1,300,000

Aspirin chemoprophylaxis†

50

590,000

Colorectal cancer screening

35

310,000

Influenza immunization (adults)

36 (50 to 64 years of age)

110,000

65 (65 years or older)

Breast cancer screening

68

91,000

Problem drinking screening and brief counseling†

50

71,000

Vision screening (adults)†

50

31,000

Cervical cancer screening

79

29,000

Chlamydia screening

40

19,000

Pneumococcal immunization (adults)

56

16,000

Cholesterol screening

87

12,000


note:Childhood immunizations were omitted because of high utilization rates and low prevalence of vaccine-preventable disease.

*—Additional lifetime quality-adjusted life years saved if 90 percent of a cohort of 4 million were offered the service as recommended.

†—Based on limited available data; a utilization rate of 50 percent was assigned.

Adapted with permission from Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Soldberg LI. Priorities among effective clinical preventive services. Am J Prev Med 2006;31:57.

TABLE 2   Additional Quality-Adjusted Life Years Saved if Current Utilization of Beneficial Preventive Care Services Increased

View Table

TABLE 2

Additional Quality-Adjusted Life Years Saved if Current Utilization of Beneficial Preventive Care Services Increased

Service Current national utilization (%) Additional quality-adjusted life years saved at 90 percent utilization*

Tobacco-use screening and brief intervention

35

1,300,000

Aspirin chemoprophylaxis†

50

590,000

Colorectal cancer screening

35

310,000

Influenza immunization (adults)

36 (50 to 64 years of age)

110,000

65 (65 years or older)

Breast cancer screening

68

91,000

Problem drinking screening and brief counseling†

50

71,000

Vision screening (adults)†

50

31,000

Cervical cancer screening

79

29,000

Chlamydia screening

40

19,000

Pneumococcal immunization (adults)

56

16,000

Cholesterol screening

87

12,000


note:Childhood immunizations were omitted because of high utilization rates and low prevalence of vaccine-preventable disease.

*—Additional lifetime quality-adjusted life years saved if 90 percent of a cohort of 4 million were offered the service as recommended.

†—Based on limited available data; a utilization rate of 50 percent was assigned.

Adapted with permission from Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Soldberg LI. Priorities among effective clinical preventive services. Am J Prev Med 2006;31:57.



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