New Preventive Services, Screening Recommendations Dominate Patient Care

New recommendations for immunizations and clinical preventive services came fast and furious in 2011, with the AAFP playing a key role in formulating many of the changes. The FDA also made headlines last year, launching dozens of actions aimed at pharmaceutical and medical device manufacturers, as well as the tobacco industry. Meanwhile, the Academy fought its own the battle against tobacco, even as it heightened its efforts to combat obesity by announcing a plan to take the fight to the nation's family medicine residencies. And, as always, chronic disease and other public health threats commanded the attention of the nation's family physicians.

On the vaccines front, the CDC's Advisory Committee on Immunization Practices, or ACIP, made a host of changes in its vaccination recommendations during 2011, many of them involving the tetanus, diphtheria and acellular pertussis, or Tdap, vaccine.

After an increasing number of pertussis outbreaks prompted the CDC to issue a health alert in mid-February, the ACIP called for all health care personnel who had not received the Tdap vaccine to receive a single dose as soon as feasible -- regardless of the interval since their last dose of a tetanus toxoid-containing vaccine. That brought health care personnel in line with the ACIP's earlier expanded recommendations for Tdap vaccine, which called for the vaccine to be administered to adults ages 65 and older who have close contact with infants, as well as to undervaccinated children ages 7-10 years.

In addition, the committee adopted a provisional recommendation in June stating that pregnant women who have never received the Tdap vaccine should be immunized during their second or third trimester rather than in the immediate postpartum period.

The ACIP also agreed in October on a provisional recommendation to expand the routine use of quadrivalent human papillomavirus, or HPV, vaccine to adolescent boys and young men. Because of the lackluster number of girls getting the three-dose HPV vaccine series, the committee voted to recommend routine use of quadrivalent HPV vaccine in adolescent boys to aid in halting spread of the infection to females, among other things. During the same meeting, the group voted to recommend the use of hepatitis B vaccine in all adults with diabetes who are younger than 60 and who have not previously received the vaccine.

Most recently, a vote by the FDA's Vaccines and Related Biologics Advisory Committee to expand the indication for 13-valent pneumococcal conjugate vaccine to include adults 50 and older is expected to pave the way for yet another new ACIP immunization recommendation. The full FDA announced its approval of the committee's proposal on Dec. 30.

The U.S. Preventive Services Task Force, or USPSTF, also was busy in 2011, making a number of recommendations intended to change clinical practice.

The task force began the year by recommending that physicians expand osteoporosis screening to include all postmenopausal women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors. The recommendation would pertain to postmenopausal women younger than 65 who have specific risk factors for the disease, such as smoking or excessive alcohol use.

In August, the USPSTF updated its recommendation against screening asymptomatic adults for bladder cancer, stating that evidence is insufficient to assess the balance of benefits and harms of screening. Previously, the task force had recommended against such screening.

Arguably, one of the most high-profile changes came in October in the form of a draft recommendation against prostate-specific antigen-based screening for prostate cancer in asymptomatic men. The USPSTF indicated that the service has no net benefit and discouraged its use. During the ensuing comment period, the AAFP expressed its support for the draft recommendation, as well as for the task force's evidence-based process for formulating such proposals and said it would review its own screening recommendation in light of this new information.

The task force also updated its screening guidelines for both adult obesity and cervical cancer in November, issuing draft recommendations that call for increased behavioral counseling interventions for patients who are obese and that limit the number of Pap smears recommended to one every three years in women ages 21-65 who have had vaginal sex and have a cervix.

During the same November meeting, the task force released a draft recommendation encouraging physicians to counsel fair-skinned individuals ages 10-24 years to minimize exposure to ultraviolet radiation to prevent skin cancer.

It's also worth noting that in August, HHS approved eight recommendations proposed in an Institute of Medicine report that are expected to expand women's access to clinical preventive services. Specifically, the agency called for new health plans (i.e., plans established on or after Sept. 23, 2010) to cover the services, which include well-woman visits, domestic violence screening and counseling, and HIV screening and counseling, without cost-sharing for plan years beginning on or after Aug. 1, 2012.

Also in 2011, the FDA began the process of restricting access to rosiglitazone-containing medications, directing physicians who wished to continue prescribing the diabetes drug to enroll themselves and their affected patients in a risk evaluation and mitigation strategy, or REMS, program by Nov. 18.

Another FDA REMS program made news earlier in the year, when the agency announced it would require manufacturers of long-acting and extended-release opioids to develop a REMS that would include voluntary CME for prescribers of the drugs in an effort to reduce abuse of the products. The FDA decision accompanied a plan -- unveiled by the White House on April 19 -- that would require physicians and other health care professionals seeking to obtain or renew a DEA registration number to complete CME related to responsible opioid prescribing practices.

The mandatory nature of the administration's plan was not well-received by many family physicians, and, in August, (then) AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, penned an editorial proclaiming the Academy's view that requiring physicians to complete CME to prescribe opioids is unnecessary and most likely will restrict access to these pain medications for patients who need them.

Also controversial was a last-minute HHS decision to countermand FDA approval of OTC access to a specific emergency contraceptive for girls younger than 17. That mid-December pronouncement drew comments both pro and con from AAFP members.

Prevention was, as always, a major component of the AAFP's mission to serve patients and their communities in 2011. The Academy continued its efforts to combat tobacco use with its long-standing Tar Wars program and its recently completed Office Champions Tobacco Cessation Pilot Project, while the FDA moved a step closer to its goal of adding graphic warnings to cigarette packs that leave little to the imagination about the deadly effects of smoking.

The Academy's Americans in Motion-Healthy Interventions program -- better known as AIM-HI -- announced in August that it was seeking applications for grants to fund childhood obesity projects in family medicine residencies around the country. AIM-HI grants of $10,000 to $30,000 will be awarded to between 10 and 18 residency programs to develop one-year, family-centered, community projects designed to reduce childhood obesity and promote fitness.

Healthier communities also are the focus of an AAFP Foundation initiative announced in November. The initiative is based on a report that examines how the theory of behavioral economics can provide a different, more informed approach to dealing with chronic health issues. To test the report's findings, the foundation will develop and implement a community-based program in Birmingham, Ala., designed to bring together a coalition of patients and caregivers to find ways to better manage diabetes care at the grassroots level.

In April, the Academy signed on to an HHS initiative dubbed Partnership for Patients. This collaboration of government agencies, health care industry groups, employers and other stakeholders aims to reduce the incidence of preventable hospital-acquired infections by 40 percent through the end of 2013, while also cutting preventable hospital readmissions by 20 percent.

Six months later, the AAFP joined with HHS and multiple other public and private partners to support the Million Hearts initiative, which aims to foster strategies and evidence-based interventions that will prevent 1 million strokes and heart attacks in the next five years.

Finally, just last month, the AAFP pledged its support for the CDC's Up and Away and Out of Sight educational campaign, which is intended to provide family physicians and other health care professionals with the tools they need to help inform their patients about the dangers of leaving medications out on low tables and counters where children can reach them.