Practice Guidelines

Partnership for Prevention Ranks Preventive Services

AMBER HUNTZINGER

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 chemoprophylaxis	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 immunization series	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).	3§	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	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.	5§	2§	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.	3§	3§	6
Vision screening (children)	Routinely screen children younger than five years for amblyopia, strabismus, and visual acuity.	2	4§	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	3§	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	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) 65 (65 years or older)	110,000
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.

Practice Guideline Briefs

ACIP Updates Mumps Vaccination Schedule

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention has updated its recommendations for mumps vaccination and immunity. The recommendations appear in the June 9, 2006, issue of Morbidity and Mortality Weekly Report.

Failure to control infection has occurred in hospitals and long-term care facilities that house adolescent or young adult patients, resulting in nosocomial transmission. When exposed to an outbreak of mumps, those same health care settings can experience unexpected costs, which may include reassignment of staff members or the closure of wards.

From January 1 through May 2, 2006, there were 2,597 reported cases of mumps in 11 states. This outbreak emphasized the limitations of the 1998 recommendations on the prevention of mumps transmission in health care and other high-risk settings.

Documentation of adequate vaccination, laboratory evidence of immunity, birth before 1957, or documentation of physician-diagnosed mumps presume acceptable evidence of immunity to mumps. However, documented evidence of immunity is now defined as one dose of a live mumps virus vaccine for preschool-age children and adults who are not at high risk for mumps, or two doses for school-age children and high-risk adults such as health care professionals, college students, and international travelers.

It is recommended that family physicians and other health care professionals be immune to mumps. Health care professionals who were born during or after 1957 should receive two doses of a live mumps virus vaccine to achieve adequate vaccination. Those with no history of a mumps vaccination and no other evidence of immunity should receive two doses, and health care professionals who have received only one dose previously should be given a second dose.

Health care facilities should consider recommending one dose of a live mumps virus vaccine to their unvaccinated health care employees who were born before 1957 who do not have a history of physician-diagnosed mumps or laboratory evidence of immunity. A second dose of the mumps vaccine also is recommended for children one to four years of age or for adults who have received only one dose.

These new recommendations for health care professionals may offer increased protection against mumps during an outbreak; however, reviewing the vaccination status of health care professionals may be inefficient, and facilities may want to consider only a routine review of immunity status while still providing other annual disease-prevention measures.

SHERRI DAMLO

Noncontraceptive Uses of the Levonorgestrel Intrauterine System

Although the levonorgestrel-releasing intrauterine system (Mirena) is approved for contraception, it also may have noncontraceptive uses, such as treating idiopathic menorrhagia. The American College of Obstetricians and Gynecologists published a committee opinion in the June 2006 issue of Obstetrics & Gynecology to address the noncontraceptive uses of this system.

The levonorgestrel intrauterine system reduces up to 86 percent of menstrual blood loss after three months in women with idiopathic menorrhagia and up to 97 percent after 12 months. At 12 months after insertion of the system, reported rates of amenorrhea vary from 20 to 80 percent. It is suggested that the levonorgestrel intrauterine system is significantly more effective than oral cyclical norethindrone as a treatment for heavy menstrual bleeding.

However, discontinuing use of the levonorgestrel intrauterine system may result in irregular bleeding, mood swings, acne, breast tenderness, and other hormonal side effects.

Hormone therapy regimens that combine estradiol-delivering methods (i.e., oral, gel, transdermal, or vaginal ring) with the levonorgestrel intrauterine system can effectively reduce climacteric symptoms and induce amenorrhea in 59 to 83 percent of women after one year. However, the long-term effects are unknown.

It is suggested that physicians evaluate women with persistent bleeding in a typical manner regardless of their use of the levonorgestrel intrauterine system.

Oral progestin therapy also is recommended as a treatment option for patients with atypical endometrial hyperplasia, with results consistent with other progestational agents.

Use of the levonorgestrel intrauterine system may be cautiously considered for patients with previous breast cancer who have used tamoxifen (Nolvadex) for more than one year; the system may prevent tamoxifen-induced endometrial changes. However, long-term randomized trials are needed before the levonorgestrel intrauterine system can be recommended as an adjuvant therapy with tamoxifen in women with a history of breast cancer.

It is reasonable to consider use of the levonorgestrel intrauterine system by women with endometriosis who desire effective, long-term contraception.

Physicians are advised to consider the levonorgestrel intrauterine system as an option for the treatment of idiopathic menorrhagia, but additional studies are required to recommend it as a reliable treatment option for endometriosis-associated pelvic pain, endometrial adenocarcinoma, hyperplasia, or as an adjuvant therapy with tamoxifen.

SHERRI DAMLO

Answers to This Issue's Clinical Quiz Q1.C Q2.C Q3. D Q4. D Q5. C Q6. B Q7. D Q8. B Q9. B, C, D Q10. B, C, D Q11. B, C, D Q12. A, B, C, D Q13. A, B, C

Copyright © 2006 by the American Academy of Family Physicians. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.