Time is at the heart of most clinical encounters. The patient presents to the office with complaints; the time required to address those complaints often overrides the delivery of routine preventive care. Other competing priorities and barriers that jeopardize the effective delivery of clinical preventive services include uncertainty about conflicting recommendations and lack of training in prevention.1 Again, time is the villain; there is precious little time available for physicians to become completely familiar with the evidence for or against the routine delivery of specific clinical preventive services.
This lack of time results in preventive care not being adequately provided by primary care physicians in the United States.2 Yet, the evidence base for the effectiveness of many preventive services does exist, and it is continually being expanded and updated. Without a working knowledge of this evidence, physicians are subject to the whims of patient demand for preventive services (often fueled by Internet information, media reports and direct-to-consumer advertising), even when that demand runs counter to the evidence for effectiveness. Furthermore, because the provision of preventive care always costs patients something—whether money, time, or physical or emotional comfort—physicians and their patients need to know that the chosen preventive service is worth the costs.
The new series of evidence-based case studies in preventive care that begins in this issue of American Family Physician3 is an effort by the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), to help family physicians become more knowledgeable about ways to incorporate evidence-based preventive care into every encounter with their patients. We aim to do this by presenting physicians with timely, interesting, case-based clinical prevention scenarios that, in a minimal amount of time, will provide the supporting evidence and practical information needed to implement these interventions in the office.
This monthly series of case studies is based on evidence amassed by the U.S. Preventive Services Task Force (USPSTF) and on the “Clinician's Handbook of Preventive Services, 2nd ed.,”4 part of AHRQ's Put Prevention Into Practice (PPIP) program (the handbook and other PPIP materials are available online at http://www.ahrq.gov/ppip). The USPSTF is a government-appointed panel of independent experts that was first established in 1984 to systematically review the evidence of effectiveness of a wide range of clinical preventive services, including common screening tests, counseling interventions, immunizations, and chemoprophylactic agents such as aspirin and hormone therapy. The first USPSTF “Guide to Clinical Preventive Services” was published in 1989. The second edition of the guide,5 published in 1996, evaluated more than 200 preventive interventions for 70 conditions. The second edition is available online at http://text.nlm.nih.gov and at http://odphp.osophs.dhhs.gov/pubs/guidecps.
This year, a newly appointed USPSTF (convened by AHRQ in November 1998) will begin the process of releasing new assessments and updates of previously issued recommendations as they are completed. Individual task force assessments will be available online through the AHRQ Web site (http://www.ahrq.gov) and in print. AHRQ's PPIP program will disseminate the USPSTF recommendations to clinicians, policymakers and patients. As part of its work, the task force is identifying areas in which to refine its methodology for assessing preventive services, including the following: developing more specific information on the benefits and risks of preventive services to assist shared decision making; expanding consideration of costs and cost-effectiveness; and focusing more attention on specific screening issues such as when to start, when to stop and intervals at which screening is beneficial.6
In addition to supporting the USPSTF and implementing PPIP, AHRQ—in partnership with the American Medical Association and the American Association of Health Plans—has established the World Wide Web-based National Guideline Clearinghouse (NGC) to provide one-stop–shopping for best practices in clinical care, including clinical preventive services. The NGC is available free of charge at http://www.guideline.gov. This site provides rapid, easy access to key recommendations of more than 700 clinical practice guidelines, with more being added every week. For the family physician, it offers the opportunity to review and evaluate comprehensive sources of information to assist with clinical decision-making and patient counseling in the clinical practice setting.
The importance of providing appropriate clinical preventive services routinely is well documented. The evidence base supporting the use of these services is continually being expanded and refined to resolve remaining areas of controversy and address new issues. The challenge for physicians is to take the time to translate the evidence into routine clinical practice. We sincerely hope that this new series will help family physicians meet that challenge.