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Am Fam Physician. 2006;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

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.

Clinically preventable burdenCost-effectivenessTotal
Aspirin chemo-prophylaxisTo 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.5510
Childhood immunizationseriesImmunize children with diphtheria, tetanus, pertussis; measles, mumps, rubella; inactivated polio virus;Haemophilus influenzae type b; hepatitis B; varicella, pneumococcal conjugate; and influenza vaccines.5510
Tobacco-use screening and brief interventionScreen adults for tobacco use, provide brief counseling, and offer pharmacotherapy.5510
Colorectal cancer screeningRoutinely screen adults 50 years and older with fecal occult blood testing, sigmoidoscopy, or colonoscopy.448
Hypertension screeningRoutinely measure blood pressure in adults, and treat with antihypertensive medication to prevent cardiovascular disease.538
Influenza immunization (adults)Immunize adults 50 years and older against influenza annually.448
Pneumococcal immunization (adults)Immunize adults 65 years and older against pneumococcal disease (one dose is adequate for most persons in this population).3§58
Problem drinking screening and brief counselingRoutinely screen adults for alcohol use that places them at increased risk, and provide brief counseling with follow-up.44§8
Vision screening (adults)Routinely screen adults 65 years and older for visual acuity with the Snellen chart.358
Cervical cancer screeningWithin 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.437
Cholesterol screeningRoutinely 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 screeningRoutinely 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.426
Chlamydia screeningRoutinely screen sexually active women younger than 25 years for chlamydia.246
Calcium chemoprophylaxisCounsel 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.24§6
Folic acid chemoprophylaxisRoutinely counsel women of childbearing age on the use of folic acid supplements to prevent birth defects.235
Obesity screeningRoutinely 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.325
Depression screeningScreen adults for depression in clinical practices with systems in place to ensure accurate diagnosis, treatment, and follow-up.314
Hearing screeningScreen adults 65 years and older for hearing impairment, and make referrals to subspecialists.224
Injury prevention counselingAssess 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).13§4
Osteoporosis screeningRoutinely 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.224
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.11§2
Diabetes screeningScreen 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.112
Diet counselingOffer intensive behavioral dietary counseling to adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.112
Tetanus-diphtheria boosterImmunize adults every 10 years.112


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.

ServiceCurrent national utilization (%)Additional quality-adjusted life years saved at 90 percent utilization*
Tobacco-use screening and brief intervention351,300,000
Aspirin chemoprophylaxis50590,000
Colorectal cancer screening35310,000
Influenza immunization (adults)36 (50 to 64 years of age)110,000
65 (65 years or older)
Breast cancer screening6891,000
Problem drinking screening and brief counseling5071,000
Vision screening (adults)5031,000
Cervical cancer screening7929,000
Chlamydia screening4019,000
Pneumococcal immunization (adults)5616,000
Cholesterol screening8712,000

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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Copyright © 2006 by the American Academy of Family Physicians.

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