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Warning:
This site is being maintained for historical purposes, but has had no new entries since October 1998. To find more recent articles, please visit the following:
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Guide To Clinical Preventive Services; An Assessment of the Effectiveness of 169 Interventions
Report of the U.S. Preventive Services Task Force; Williams & Wilkins, (MAY OBTAIN A COPY FOR $30.00. TO ORDER CALL 1-800-638-0672 OR WRITE TO ADDRESS AT THE END OF THIS DOCUMENT)
Publication date: 10/01/1989
Table of Contents
The Periodic Health Examination: Age-Specific Charts
The Periodic Health Examination: Age-Specific Charts
Table 5: Leading Causes of Death, Birth to 18 Months
Table 6: Leading Causes of Death, Ages 2-6
Table 7:Leading Causes of Death, Ages 7-12
Table 8:Leading Causes of Death, Ages 13-18
Table 9:Leading Causes of Death, Ages 19-39
Table 10: Leading Causes of Death, Ages 40 -64
Table 11: Leading Causes of Death, Ages 65 and Over
Table 12: Pregnant Women
REFERENCES
Recommendations for Patient Education and Counseling
References
Screening for Asymptomatic Coronary Artery Disease
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for High Blood Cholesterol
Recommendation
Burden of Suffering
Efficacy of Screening Test
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Hypertension
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Notes
References
Screening for Cerebrovascular Disease
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Peripheral Arterial Disease
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Screening for Breast Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Colorectal Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Cervical Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Test
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Prostate Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
References
Screening for Lung Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Skin Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Testicular Cancer
Recommendation
Burden of Suffering
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Ovarian Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
References
Screening for Pancreatic Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Oral Cancer
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Diabetes Mellitus
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Thyroid Disease
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
References
Screening for Obesity
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Phenylketonuria
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
References
Screening for Hepatitis B
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
Note
References
Screening for Tuberculosis
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
Note
References
Screening for Syphilis
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
Note
References
Screening for Gonorrhea
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Infection with Human Immunodeficiency Virus
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Chlamydial Infection
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Genital Herpes Simplex
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
Note
References
Screening for Asymptomatic Bacteriuria, Hematuria, and Proteinuria
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Note
References
Screening for Anemia
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Hemoglobinopathies
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Lead Toxicity
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
References
Screening for Diminished Visual Acuity
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Glaucoma
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Hearing Impairment
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Intrauterine Growth Retardation
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Preeclampsia
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Rubella
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Rh Incompatibility
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Congenital Birth Defects
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
References
Screening for Fetal Distress
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Postmenopausal Osteoporosis
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Risk of Low Back Injury
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Dementia
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Abnormal Bereavement
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Screening for Depression
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Screening for Suicidal Intent
Recommendation:
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Clinical Intervention
Note
References
Screening for Violent Injuries
Recommendation
Burden of Suffering
Efficacy of Screening
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention:
Note
References
Screening for Alcohol and Other Drug Abuse
Recommendation
Burden of Suffering
Efficacy of Screening Tests
Effectiveness of Early Detection
Recommendations of Others
Discussion
Clinical Intervention
References
Counseling to Prevent Tobacco Use
Recommendation
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Exercise Counseling
Recommendation
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Nutritional Counseling
Recommendation:
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Clinical Intervention
Note
References
Counseling to Prevent Motor Vehicle Injuries
Recommendation
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Counseling to Prevent Household and Environmental Injuries
Recommendation:
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Counseling to Prevent Human Immunodeficiency Virus Infection and OthSexually Transmitted Diseases
Recommendation
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Counseling to Prevent Unintended Pregnancy
Recommendation
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Counseling to Prevent Dental Disease
Recommendation
Burden of Suffering
Efficacy of Risk Reduction
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Childhood Immunizations
Recommendation
Burden of Suffering
Efficacy of Vaccines
Recommendations of Others
Clinical Intervention
Note
References
Adult Immunizations
Recommendation
Burden of Suffering
Efficacy of Vaccines
Recommendations of Others
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Postexposure Prophylaxis
Recommendation
Recommendation
Burden of Suffering
Efficacy of Prophylaxis
Recommendations of Others
Clinical Intervention
Note
References
Estrogen Prophylaxis
Recommendation
Burden of Suffering
Efficacy of Chemoprophylaxis
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
Note
References
Aspirin Prophylaxis
Recommendation
Burden of Suffering
Efficacy of Chemoprophylaxis
Effectiveness of Counseling
Recommendations of Others
Discussion
Clinical Intervention
References
Appendix A; Task Force Ratings
Quality of Evidence
Table 13:Breast Cancer Screening
Table 14:Screening for Diabetes Mellitus
Table 15:Colorectal Cancer Screening
Table 16:Prevention od Sexually Transmitted Diseases
Table 17:Automobile Occupant Protection Counseling
Table 18:Dipstick Urinalysis
Table 19:Smoking Cessation Counseling
Table 20:Physical Activity Counseling
Table 21:dietary Fat Counseling
Table 22:Fall Protection Among Older Adults
Table 23:Prevention of Unwanted Adolescent Pregnancy
Table 24:Preventive Dentistry
Table 25:Immunizations, Immunoprophylaxis, and Chemoprophylaxis to
POINT OF CONTACT FOR THIS DOCUMENT:
Tables
Criteria For Effectiveness
Definition Of Terms
Positive Predictive Value (PPV) And Prevalence
Effect Of Mortality Rate On Total Deaths Prevented
Birth To 18 Months
Ages 2-6
Ages 7-12
Ages 13-18
Ages 19-39
Ages 40-64
Ages 65 And Over
Pregnant Women
Breast Cancer Screening
Screening For Diabetes Mellitus
Colorectal Cancer Screening
Prevention Of Sexually Transmitted Diseases
Automobile Occupant Protection Counseling
Dipstick Urinalysis
Smoking Cessation Counseling
Physical Activity Counseling
Dietary Fat Counseling
Fall Prevention Among Oldr Persons
Prevention Of Unwanted Adolescent Pregnancy
Preventive Dentistry
Immunizations, Immunoprophylaxis, And Chemoprophylaxis To Prevent
Introduction
This report is intended for primary care clinicians: physicians, nurses, nurse practitioners, physicians' assistants, other allied health professionals, and students. It provides recommendations for clinical practice on 169 preventive interventions--screening tests, counseling interventions, immunizations, and chemoprophylactic regimens--for the prevention of 60 target conditions. The patients for whom these services are recommended include asymptomatic individuals of all age groups and risk categories. Thus, the subject matter is relevant to all of the major primary care specialties: family practice, internal medicine, pediatrics, and obstetrics-gynecology. The recommendations in each chapter are based on a standardized review of current scientific evidence and include a summary of published clinical research regarding the clinical effectiveness of each preventive service. A listing of the relevant recommendations of major professional organizations and health agencies is also included for each preventive service.Clinicians have always intuitively understood the value of prevention. Faced daily with the difficult and often unsuccessful task of treating advanced stages of disease, primary care providers have long sought the opportunity to intervene early in the course of disease or even before disease develops. The benefits of incorporating prevention into medical practice have become increasingly apparent over the past 20 to 30 years as previously common and debilitating conditions have declined in incidence following the introduction of effective clinical preventive services. Infectious diseases such as poliomyelitis, which once occurred in regular epidemic waves (over 18,300 cases in 1954), have become rare in the United States as a result of childhood immunization.1 Only five cases of paralytic poliomyelitis were reported in the United States in 1987.1 Before rubella vaccine became available, rubella epidemics occurred regularly in the United States every six to nine years; a 1964 pandemic resulted in over 12 million rubella infections, with over 11,000 fetal losses and about 20,000 infants born with congenital rubella syndrome.2,3 The incidence of rubella has decreased 99% since 1969, when the vaccine first became available.4,5 Similar trends have occurred with diphtheria, pertussis, and other once-common childhood infectious diseases.(1)
Preventive services for the early detection of disease have also been associated with dramatic reductions in morbidity and mortality. Age-adjusted mortality from strokes has decreased by more than 50% since 1972, a trend attributed in part to earlier detection and treatment of hypertension.(6,7) Cervical cancer mortality has fallen by 73% since 1950,(8) due in part to widespread Papanicolaou testing to detect cervical dysplasia.(9,10) Children with metabolic disorders such as phenylketonuria and congenital hypothyroidism, who once suffered severe irreversible mental retardation, now usually retain normal cognitive function as a result of routine newborn screening and treatment.(11-13)
Although immunizations and screening tests remain important preventive services, the most promising role for prevention in current medical practice may lie in changing the personal health behaviors of patients long before clinical disease develops. The importance of this aspect of clinical practice is demonstrated by a growing body of evidence linking a handful of personal health behaviors to the leading causes of death in the United States: heart disease, cancer, cerebrovascular disease, injuries, and chronic obstructive pulmonary disease.(14) Smoking alone contributes to one out of every six deaths in the United States,(15) including 130,000 deaths each year from cancer, 115,000 from coronary artery disease, 27,500 from cerebrovascular disease, and 60,000 from chronic obstructive pulmonary disease.(16) Failure to use safety belts and driving while intoxicated are major contributors to motor vehicle injuries, which accounted for over 47,000 deaths in 1987.(14) Physical inactivity and dietary factors contribute to coronary atherosclerosis, cancer, diabetes, osteoporosis, or other common diseases.(17-20) Certain sexual practices increase the risk of unintended pregnancy, sexually transmitted diseases, and acquired immunodeficiency syndrome.(21,22)
Although there are sound clinical reasons for emphasizing prevention in medicine, studies have shown that physicians often fail to provide recommended clinical preventive services.(23) This is due to a variety of factors, including lack of reimbursement for preventive services.(24) Also, busy clinicians often have insufficient time with patients to deliver the range of preventive services that are recommended. But even when these barriers to implementation are accounted for, clinicians fail to perform preventive services as recommended.(25) One reason for this is uncertainty among clinicians as to which services should be offered.
Part of the uncertainty among clinicians derives from the fact that recommendations come from multiple sources, and these recommendations are often different. Recommendations relating to clinical preventive services are issued regularly by Government health agencies,(6,26-28) medical specialty organizations, (29-35) professional and scientific organizations, (36-38) voluntary associations, (39-41) and individual experts.(42-47)
In addition, a major reason clinicians may be reluctant to perform preventive services is skepticism about their clinical effectiveness. It is often unclear whether performance of certain preventive interventions can significantly reduce morbidity or mortality from the target condition the clinician is attempting to prevent. It is also unclear how to compare the relative effectiveness of different preventive services, making it difficult for busy clinicians to decide which interventions are most important during a brief patient visit. A broader concern is that some maneuvers may ultimately result in more harm than good. While this concern applies to all clinical practices, it is especially important in relation to preventive services because the individuals who receive these interventions are often relatively healthy. Minor complications or rare adverse effects that would be tolerated in the treatment of a severe illness take on greater significance in the asymptomatic population and require careful evaluation to determine whether benefits exceed risks. Moreover, preventive services such as routine screening are often recommended for a large proportion of the population, and there are therefore potentially significant economic implications to implementation.
These uncertainties increasingly have raised questions about the value of the routine health examination of asymptomatic persons, in which the same battery of tests and physical examination procedures are performed as part of a routine checkup. The annual physical examination of healthy persons was first proposed by the American Medical Association in 1922.48 For many years after, it was common practice among health professionals to recommend routine physicals and comprehensive laboratory testing as effective preventive medicine. It is now increasingly clear, however, that while routine visits with the primary care clinician are important, performing the same interventions on all patients and performing them as frequently as every year are not the most clinically effective approaches to disease prevention. Rather, both the frequency and the content of the periodic health examination need to be tailored to the unique health risks of the individual patient and should take into consideration the quality of the evidence that specific preventive services are clinically effective. This approach to the periodic visit was endorsed by the American Medical Association in 1983 in a policy statement that withdrew support for a standard annual physical examination.(36)Current thinking is that the individualized periodic health visit should place greater emphasis on evidence of clinical effectiveness, and thus increased attention is turning to the collection of reliable data on the effectiveness of specific preventive services.
One of the first comprehensive efforts to examine these issues systematically was undertaken by the Canadian government, which in 1976 convened the Canadian Task Force on the Periodic Health Examination. This expert panel adopted a highly organized approach to evaluating the effectiveness of clinical preventive services. Explicit criteria were developed to judge the quality of evidence from published clinical research, and uniform decision rules were used to link the strength of recommendations for or against a given preventive service to the quality of the underlying evidence (see Appendix A). These ratings were intended to provide the clinician with a means of selecting those preventive services supported by the strongest evidence of effectiveness. Using this approach, the Canadian Task Force examined preventive services for 78 target conditions, releasing its recommendations in a monograph published in 1979.(49) In 1982, the Canadian Task Force reconvened and applied its methodology to new evidence as it became available, publishing revised recommendations and evaluations of new topics in 1984, 1986, and 1988.(50-52)
A similar effort was launched in the United States in 1984, when Edward N. Brandt, M.D., Ph.D., the Assistant Secretary for Health of the Department of Health and Human Services, commissioned the U.S. Preventive Services Task Force. This 20-member non-Federal panel included 14 physicians with expertise in primary care medicine (family practice, internal medicine, and pediatrics), clinical epidemiology, and public health. The panel also included a dentist, a nurse, a health services researcher, a health educator, a health economist, and a medical sociologist. Like the Canadian panel, the U.S. Task Force was charged with developing recommendations for clinicians on the appropriate use of preventive interventions, based on a systematic review of evidence of clinical effectiveness.53 A similar methodology was adopted at the outset of the project. This enabled the U.S. and Canadian panels to collaborate in a binational effort to review evidence and develop recommendations on preventive services.
The U.S. Task Force met 14 times between July 1984 and February 1988. Its objective was to develop comprehensive recommendations addressing preventive services for all age groups. The panel members and their scientific support staff, based at the Office of Disease Prevention and Health Promotion of the Department of Health and Human Services, reviewed evidence and developed recommendations on preventive services for 60 target conditions affecting patients from infancy to old age. This report, which summarizes the findings and clinical recommendations of the panel, was prepared by the scientific staff of the Task Force in the final year of the project (1988-1989). Both the meetings of the Task Force and the preparation of this work have been carried out in close collaboration with professional organizations throughout the United States and with U.S. Government agencies that share an interest in prevention.
Several important findings have emerged from the review of evidence in this report. First, the data suggest that among the most effective interventions available to clinicians for reducing the incidence and severity of the leading causes of disease and disability in the United States are those that address the personal health practices of patients. Primary prevention as it relates to such risk factors as smoking, physical inactivity, poor nutrition, and alcohol and other drug abuse holds generally greater promise for improving overall health than many secondary preventive measures such as routine screening for early disease. Although certain screening tests, such as mammography (54) and Papanicolaou smears, (55) can be highly effective in reducing morbidity and mortality, the Task Force found that many others are of unproven effectiveness. Screening tests with inadequate accuracy, when performed routinely without regard to risk factors, often produce large numbers of false-positive results that may result in unnecessary diagnostic testing and treatment. Many tests that lack evidence of improved clinical outcome have the additional disadvantage of being expensive, especially when performed on large numbers of persons in the population.
Thus, the second principal finding of this report is the need for greater selectivity in ordering tests and providing preventive services. In particular, the proper selection of screening tests requires careful consideration of the age, sex, and other individual risk factors of the patient if the clinician is to minimize the risk of adverse effects and unnecessary expenditures due to screening (see Methodology). An appreciation of the risk profile of the patient is also necessary to determine which interventions are most important during the clinical encounter. The need for evaluating risk factors underscores a time-honored principle of medical practice: the importance of a complete medical history and detailed discussion with patients regarding personal health practices.
The third principal finding of the Task Force report is that conventional clinical activities (e.g., diagnostic testing) may be of less value to patients than activities once considered outside the traditional role of the clinician (e.g., counseling and patient education). This suggests a new paradigm in defining the responsibilities of the primary care provider. In the past, the role of the clinician related primarily to the treatment of illnesses; the asymptomatic healthy individual did not need to see the doctor. In addition, personal health behaviors were often not viewed as a legitimate clinical issue. A patient's use of safety belts, for example, would receive less attention from the clinician than the results of a complete blood count (CBC) or a routine chest xray. A careful review of the data, however, suggests that different priorities are in order. Motor vehicle injuries affect nearly 4 million persons each year in the United States; (56) they account for over 45,000 deaths each year and are a leading cause of death in persons aged 5-44.(14) Proper use of safety belts can prevent 40-60% of motor vehicle injuries and deaths.(57,58) In contrast, there is little good evidence that performing routine CBCs or chest x-rays improves clinical outcome, (59,60) and these procedures are associated with increased health care expenditures.
The fourth finding is that the shifting responsibility of clinicians also implies a changing role for patients. The increasing evidence of the importance of personal health behaviors and primary prevention means that patients must assume greater responsibility for their own health. Whereas the clinician is often the key figure in the treatment of acute illnesses and injuries, the patient is the principal effector in primary prevention. In the traditional doctor-patient relationship, the patient adopts a passive role and expects the doctor to assume control of the treatment plan. One of the initial tasks of the clinician practicing primary prevention is shifting the locus of control to the patient. To achieve competence in this task, some clinicians may need to develop new skills in helping to empower patients and in counseling them to change certain health related behaviors.
Fifth, preventive services need not be delivered exclusively during visits devoted entirely to prevention. While preventive checkups often provide more time for counseling and other preventive services, and although healthy individuals may be more receptive to such interventions than those who are sick, the illness visit is an equally important time to practice prevention. In fact, some individuals may see clinicians only when they are ill or injured. The illness visit may provide the only opportunity to reach such individuals who, due to limited access to care, would be otherwise unlikely to receive preventive services. For many conditions, the Task Force found that devising strategies to increase access to preventive services for such individuals is more likely to reduce morbidity and mortality than performing preventive services more frequently on those who are already regular recipients of preventive care and who are often in better health.
Sixth, the gaps in evidence identified by the Task Force underscore the size of the research agenda in preventive medicine. For most topics examined in this report, the Task Force found inadequate evidence to evaluate effectiveness or to determine the optimal frequency of a preventive service. In some cases, the necessary studies have never been performed. But for many other topics, studies have been performed--in some cases, large numbers of studies--but the findings are unreliable because of improper study design or systematic biases. Thus, while it is certainly important to perform more research in preventive medicine, there is an even greater need in prevention and other medical specialties for better quality research in evaluating effectiveness. The studies reviewed in this report suggest that clinical researchers evaluating effectiveness often fail to give adequate attention to potential flaws in the design of their studies. This observation confirms the findings of other reviewers regarding the need to improve the overall methodologic quality of clinical research. (61)
Finally, the process used by the U.S. and Canadian Task Forces to evaluate effectiveness may be as important a contribution to medical policy as are the recommendations themselves. Although only preventive services have been examined in this report, the techniques that have been developed by the U.S. Task Force for the standardized review of evidence and for developing clinical practice recommendations based on documented decision rules are equally applicable to many other medical practices. The availability of such techniques comes at a time when increasing attention is being focused on devising better methods for evaluating effectiveness in clinical practice.(62) The methodology presented in this report may be useful to others who share an interest in using systematic methods for reviewing published clinical research and assessing the overall health effects of clinical practices.
It is hoped that this report will help resolve some of the uncertainties among primary care clinicians regarding the effectiveness of preventive services. A comprehensive approach has been taken to explore issues of prevention for a wide range of disease categories and for patients of all ages. The systematic approach to the review of evidence for each topic should provide clinicians with the means to compare the relative effectiveness of different preventive services and to determine, on the basis of scientific evidence, what is most likely to benefit their patients. Basing such decisions on rigorous research will be an important step forward in the advancement of disease prevention and health promotion in the United States.
References
1. Centers for Disease Control. Summary of notifiable diseases, United States, 1987. MMWR 1988; 36:1-59.
2. Witte JJ, Karchmer AW, Case G, et al. Epidemiology of rubella. Am J Dis Child 1969; 118:107-11.
3. Orenstein WA, Bart KJ, Hinman AR, et al. The opportunity and obligation to eliminate rubella from the United States. JAMA 1984; 251:1988-94. 4. Centers for Disease Control. Rubella and congenital rubella--United States, 1984-1986. MMWR 1987; 36:664.
5. Idem. Rubella and congenital rubella syndrome--New York City. MMWR 1986; 35:770-9.
6. 1988 Joint National Committee. The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1988; 148:1023-38.
7. Garraway WM, Whisnant JP. The changing pattern of hypertension and the declining incidence of stroke. JAMA 1987; 258:214-7.
8. National Cancer Institute. 1987 annual cancer statistics review, including cancer trends, 1950-1985. Washington, D.C.: Department of Health and Human Services, 1988. (Publication no. DHHS (NIH) 882789.) 9. Yu S, Miller AB, Sherman GJ. Optimising the age, number of tests, and test interval for cervical screening in Canada. J Epi Comm Health 1982; 36:1-10.
10. Miller AB, Visentin T, Howe GR. The effect of hysterectomies and screening on mortality from cancer of the uterus in Canada. Int J Cancer 1981; 27:651-7.
11. Berman PW, Waisman HA, Graham FK. Intelligence in treated phenylketonuric children: a developmental study. Child Develop 1966; 37:731-47.
12. Hudson FP, Mordaunt VL, Leahy I. Evaluation of treatment begun in first three months of life in 184 cases of phenylketonuria. Arch Dis Child 1970; 45:5-12.
13. Williamson ML, Koch R, Azen C, et al. Correlates of intelligence test results in treated phenylketonuric children. Pediatrics 1981; 68:161-7. 14. National Center for Health Statistics. Advance report of final mortality statistics, 1986. Monthly Vital Statistics Report (Suppl), vol. 37, no. 6. Hyattsville, Md.: Public Health Service, 1988. (Publication no. DHHS (PHS) 88-1120.)
15. Centers for Disease Control. Smoking-attributable mortality and years of potential life lost--United States, 1984. MMWR 1987; 36:6937. 16. Department of Health and Human Services. Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. Rockville, Md.: Department of Health and Human Services, 1989. (Publication no. DHHS (PHS) 89-8411.)
17. Bouchard C, Shephard RJ, Stephens T, et al., eds. Exercise, fitness, and health: research and consensus. Proceedings of the International Conference on Exercise, Fitness, and Health. Champaign, Ill.: Human Kinetics Publishers (in press).
18. Department of Health and Human Services. The Surgeon General's report on nutrition and health. Washington, D.C.: Government Printing Office, 1988. (Publication no. DHHS (PHS) 88-50210.)
19. The Lipid Research Clinics Coronary Primary Prevention Trial Results. I. Reduction in incidence of coronary heart disease. JAMA 1984; 251:351-64.
20. The Lipid Research Clinics Coronary Primary Prevention Trial Results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984; 251:365-74.
21. Hatcher RA, Guest F, Stewart F, et al. Contraceptive technology, 1988-1989. Atlanta, Ga.: Printed Matter, Inc., 1988.
22. Curran JW, Jaffe HW, Hardy AM, et al. Epidemiology of HIV infection and AIDS in the United States. Science 1988; 239:610-6.
23. Lewis CE. Disease prevention and health promotion practices of primary care physicians in the United States. Am J Prev Med (Suppl) 1988; 4:9-16.
24. Logsdon DN, Rosen MA. The cost of preventive health services in primary medical care and implications for health insurance coverage. J Ambul Care Man 1984; 46-55.
25. Lurie N, Manning WG, Peterson C, et al. Preventive care: do we practice what we preach? Am J Public Health 1987; 77:801-4.
26. National Cancer Institute. Working guidelines for early cancer detection: rationale and supporting evidence to decrease mortality. Bethesda, Md.: National Cancer Institute, 1987.
27. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med 1988; 148:36-69.
28. Immunization Practices Advisory Committee. New recommended schedule for active immunization of normal infants and children. MMWR 1986; 35:577-9.
29. American College of Physicians. Periodic health examination: a guide for designing individualized preventive health care in the asymptomatic patient. Ann Intern Med 1981; 95:729-32.
30. Idem. Common diagnostic tests: use and interpretation. Philadelphia: American College of Physicians, 1987.
31. American College of Obstetricians and Gynecologists. Standards for obstetric-gynecologic services, 6th ed. Washington, D.C.: American College of Obstetricians and Gynecologists, 1985:17-8.
32. Peter G, Giebink GS, Hall CB, et al., eds. Report of the Committee on Infectious Diseases, 20th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, 1986:266-75.
33. American Academy of Pediatrics. Guide to implementing safety counseling. Elk Grove Village, Ill.: American Academy of Pediatrics, 1985.
34. Idem. Vision screening and eye examination in children. Committee on Practice and Ambulatory Medicine. Pediatrics 1986; 77:918-9. 35. American Academy of Ophthalmology. Infants and children's eye care. Statement by the American Academy of Ophthalmology to the Select Panel for the Promotion of Child Health, Department of Health and Human Services. San Francisco, Calif.: American Academy of Ophthalmology, 1980.
36. American Medical Association. Medical evaluations of healthy persons. Council on Scientific Affairs. JAMA 1983; 249:1626-33.
37. American Dental Association. Accepted dental therapeutics, 39th ed. Chicago, Ill.: American Dental Association, 1982.
38. National Academy of Sciences, Institute of Medicine. Ad Hoc Advisory Group on Preventive Services. Preventive services for the well population. Washington, D.C.: National Academy of Sciences, 1978. 39. American Cancer Society. Report on the cancer-related health checkup. CA 1980; 30:194-240.
40. American Heart Association. Cardiovascular and risk factor evaluation of healthy American adults: a statement for physicians by an ad hoc committee appointed by the steering committee. Circulation 1987; 75:1340A-62A.
41. American Diabetes Association. Physician's guide to non-insulin dependent (type II) diabetes. Diagnosis and treatment. Alexandria, Va.: American Diabetes Association, 1988.
42. Frame PS, Carlson SJ. A critical review of periodic health screening using specific screening criteria. J Fam Pract 1975; 2:283-9. 43. Frame PS. A critical review of adult health maintenance. Part 1. Prevention of atherosclerotic diseases. J Fam Pract 1986; 22:341-6. 44. Idem. A critical review of adult health maintenance. Part 2. Prevention of infectious diseases. J Fam Pract 1986; 22:417-22.
45. Idem. A critical review of adult health maintenance. Part 3. Prevention of cancer. J Fam Pract 1986; 22:511-20.
46. Idem. A critical review of adult health maintenance. Part 4. Prevention of metabolic, behavioral, and miscellaneous conditions. J Fam Pract 1986; 23:29-39.
47. Breslow L, Somers AR. The lifetime health-monitoring program: a practical approach to preventive medicine. N Engl J Med 1977; 292:601-8.
48. American Medical Association. Periodic health examination: a manual for physicians. Chicago, Ill.: American Medical Association, 1947. 49. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1194-254.
50. Idem. The periodic health examination. 1984 update. Can Med Assoc J 1984; 130:1278-85.
51. Idem. The periodic health examination. 1986 update. Can Med Assoc J 1986; 134:721-9.
52. Idem. The periodic health examination. 1988 update. Can Med Assoc J 1988; 138:617-26.
53. Lawrence RS, Mickalide AD. Preventive services in clinical practice: designing the periodic health examination. JAMA 1987; 257:2205-7. 54. Shapiro S, Venet W, Strax P, et al., eds. Periodic screening for breast cancer. Baltimore, Md.: Johns Hopkins Press, 1988.
55. International Agency for Research on Cancer Working Group on Evaluation of Cervical Cancer Screening Programmes. Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implication for screening policies. Br Med J 1986; 293:659-64.
56. National Highway Traffic Safety Administration. National accident sampling system, 1986: a report on traffic crashes and injuries in the United States. Washington, D.C.: Department of Transportation, 1988:x. (Publication no. DOT HS 807-296.)
57. Department of Transportation. Final regulatory impact assessment on amendments to Federal Motor Vehicle Safety Standard 208, Front Seat Occupant Protection. Washington, D.C.: Department of Transportation, 1984. (Publication no. DOT HS 806-572.)
58. Campbell BJ. Safety belt injury reduction related to crash severity and front seated position. J Trauma 1987; 27:733-9.
59. Tape TG, Mushlin AI. The utility of routine chest radiographs. Ann Intern Med 1986; 104:663-70.
60. Shapiro MF, Greenfield S. The complete blood count and leukocyte differential count. Ann Intern Med 1987; 106:65-74.
61. Feinstein AR. Scientific standards in epidemiologic studies of the menace of daily life. Science 1988; 242:1257-63.
62. Institute of Medicine. Assessing medical technologies. Washington, D.C.: National Academy Press, 1985.
Methodology
This report presents a systematic approach to evaluating the effectiveness of clinical preventive services. The recommendations, and the review of evidence from published clinical research on which they are based, are the product of a methodology established at the outset of the project. The intent of this analytic process has been to provide clinicians* with current and scientifically defensible information about the relative effectiveness of different preventive services and the quality of the evidence on which these conclusions are based. This information can help clinicians who have limited time to select the most appropriate preventive services to offer in a periodic health examination for patients of different ages and risk categories. The critical appraisal of evidence is also intended to identify preventive services of uncertain effectiveness as well as those that could result in more harm than good if performed routinely by clinicians.For the content of this report to be useful, and to clarify differences between the U.S. Preventive Services Task Force recommendations and those of other groups, it is important for the reader to be aware of the process by which this report was developed, as well as how it differs from the consensus development process used to derive most clinical practice guidelines. First, the objectives of the review process, including the types of preventive services to be examined and the nature of the recommendations to be developed, were carefully defined early in the process. Second, the Task Force adopted explicit criteria for recommending the performance or exclusion of preventive services and applied these "rules of evidence" systematically to each topic it studied. Third, literature searches and assessments of the quality of individual studies were conducted in accordance with rigorous, predetermined methodologic criteria. Fourth, guidelines were adopted for translating these findings into sound clinical practice recommendations. Finally, these recommendations were reviewed extensively by experts in the United States, Canada, and the United Kingdom. Each of these steps is examined in greater detail below.
(Notes *)The provider of preventive services in primary care is often a physician. The term "clinician" is used in this report, however, to include other primary care providers such as nurses, nurse practitioners, physicians' assistants, and other allied health professionals. Although physicians may be better qualified than other providers to perform certain preventive services or to convince patients to change behavior, some preventive services are more effectively performed by nonphysicians with special training (e.g., nurses, dietitians, smoking cessation counselors, mental health professionals). **The term "asymptomatic person" as used in this report differs from its customary meaning in medical practice. Although "asymptomatic" is often considered synonymous with "healthy," the term is used in this report to describe individuals who lack clinical evidence of the target condition. Signs and symptoms of illnesses unrelated to the target condition may be present without affecting the designation of "asymptomatic." Thus, a 70-year-old man with no genitourinary symptoms who is screened for prostate cancer would be designated asymptomatic for that condition, even if he were hospitalized for (unrelated) congestive heart failure. Preventive services recommended for "asymptomatic patients" therefore need not be delivered only during preventive checkups of healthy persons but apply equally to clinical encounters with patients being seen for other reasons. In fact, the illness visit may provide the clinician with the best opportunity for delivering some preventive services. Persons in need of preventive services who have limited access to care rarely visit clinicians unless they become ill.
Definition of Objectives --
Systematic rules were used to select the target conditions and candidate preventive interventions to be evaluated by the Task Force.
Selection of Target Conditions --
The Task Force began by preparing a list of important diseases and injuries in the United States that might be preventable through clinical intervention. The 60 target conditions were selected on the basis of two important criteria:
Burden of Suffering from the Target Condition -
Conditions that are relatively uncommon in the United States or are of only minor clinical significance were not considered in this report. Thus, consideration was given to both the prevalence (proportion of the population affected) and incidence (number of new cases per year) of the condition. Conditions that were once common but have become rare because of effective preventive interventions (e.g., poliomyelitis) were included in the review.
Potential Effectiveness of the Preventive Intervention -
Conditions were excluded from analysis if the panel could not identify a potentially effective preventive intervention that could be performed by clinicians.
Selection of Preventive Services --
For each target condition, the Task Force used two criteria to select the preventive services to be evaluated. First, in general, only preventive services carried out on asymptomatic persons** were reviewed. Thus, only primary and secondary preventive measures were addressed. Primary preventive measures involve entirely asymptomatic individuals (e.g., routine immunization of healthy children), whereas secondary preventive measures identify and treat asymptomatic persons who have already developed risk factors or preclinical disease but in whom the disease itself has not become clinically apparent. Obtaining a Papanicolaou smear to detect cervical dysplasia before the development of cancer is a form of secondary prevention. Preventive measures in symptomatic patients, such as antibiotic therapy to prevent postoperative wound infection or insulin therapy to prevent the complications of diabetes mellitus, are considered tertiary prevention and are outside the scope of this report.
The second criterion for selecting preventive services for review was that the maneuver had to be performed in the clinical setting. Only those preventive services that would be carried out by clinicians in the context of routine health care were examined. Findings should not be extrapolated to preventive interventions performed in other settings. Screening tests are evaluated in terms of their effectiveness when performed during the clinical encounter (i.e., case-finding). Screening tests performed at schools, worksites, health fairs, and other community locations are not within the scope of this report. Also, preventive interventions performed outside the clinical setting (e.g., health and safety legislation, mandatory screening, community health promotion) are not specifically evaluated, although clinicians can play an important role in promoting such programs and in encouraging the participation of their patients.
After the complete set of target conditions and preventive services were identified, they were divided into three categories: screening tests, counseling interventions, and immunizations and chemoprophylaxis. Screening tests are those preventive services in which a special test or standardized examination procedure is used to identify patients requiring special intervention. Nonstandardized historical questions, such as asking patients whether they smoke, and tests involving symptomatic patients are not considered screening tests. Counseling interventions are those in which the patient receives information and advice regarding personal behaviors (e.g., diet) to reduce the risk of subsequent illness or injury. Counseling regarding the health-related behaviors of persons who have already developed signs and symptoms is specifically excluded. Immunizations discussed in this report include vaccines and immunoglobulins (passive immunization) taken by persons with no evidence of infectious disease. Chemoprophylaxis refers to the use of drugs or biologics taken by asymptomatic persons as primary prevention to reduce the risk of developing a disease.
Criteria for Determining Effectiveness --
Preventive services are required to meet predetermined criteria to be considered effective. The criteria of effectiveness for the three categories of preventive services (Table 1) provided the analytic framework for the evaluation of effectiveness in the 60 chapters in this report. Each of these criteria must be satisfied to evaluate the "causal pathway" of a preventive service, the chain of events that must occur for a preventive maneuver to influence clinical outcome.(1) Thus, a screening test is not considered effective if it lacks sufficient accuracy to detect the condition earlier than without screening or if there is inadequate evidence that early detection improves outcome. Similarly, counseling interventions cannot be considered effective in the absence of firm evidence that changing personal behavior can improve outcome and that clinicians can influence this behavior through counseling. Effective immunization and chemoprophylactic regimens require evidence of biologic efficacy; in the case of chemoprophylactic agents, evidence is also necessary that patients will comply with long-term use of the drug.
The methodologic issues involved in evaluating screening tests require further elaboration. As mentioned above, a screening test must satisfy two major requirements to be considered effective:
These two headings appear in each of the Screening sections in this report.
- The test must be able to detect the target condition earlier than without screening and with sufficient accuracy to avoid producing large numbers of false-positive and false-negative results (efficacy of screening test).
- Persons with disease who are detected early should have a better clinical outcome than those who are detected without screening (effectiveness of early detection).
Efficacy of Screening Test -
In a departure from the conventional definition of "efficacy," the term "efficacy of a screening test" is used in this report to describe accuracy and reliability. Accuracy is measured in terms of four indices: sensitivity, specificity, and positive and negative predictive value (Table 2). Sensitivity refers to the proportion of persons with a condition who correctly test "positive" when screened. A test with poor sensitivity will miss cases (persons with the condition) and will produce a large proportion of false-negative results; true cases will be told incorrectly that they are free of disease. Specificity refers to the proportion of persons without the condition who correctly test "negative" when screened. A test with poor specificity will result in healthy persons being told they have the condition (false positives). An accepted reference standard ("gold standard") is essential to determining sensitivity and specificity, because it provides the means for distinguishing between "true" and "false" test results.
The use of screening tests with poor sensitivity and/or specificity is of special significance to the clinician because of the potentially serious consequences of false-negative and false-positive results. Persons who receive false-negative results may experience important delays in diagnosis and treatment. Some might develop a false sense of security, resulting in inadequate attention to risk reduction and delays in seeking medical care when warning symptoms become present. False-positive results can lead to follow-up testing that may be uncomfortable, expensive, and, in some cases, potentially harmful. If follow-up testing does not disclose the error, the patient may even receive unnecessary treatment. There may also be psychological consequences. Persons informed of an abnormal medical test that is falsely positive may experience unnecessary anxiety until the error is corrected. Labeling may affect behavior; for example, studies have shown that some persons with hypertension identified through screening may experience altered behavior and decreased work productivity.(2,3)
A proper evaluation of a screening test must therefore include a determination of the likelihood of producing false-positive results. This is done by calculating the positive predictive value (PPV) of the test (Table 2) in the population to be screened. The PPV of a screening test is the proportion of positive results that are correct (true positives). A test with low PPV can generate more false-positive than true-positive results, but this depends to a large extent on the type of population in which it is used. The PPV increases and decreases in accordance with the prevalence of the target condition in the screened population. Thus, unlike sensitivity and specificity, the PPV is not a constant performance characteristic of a screening test. If the target condition is sufficiently rare in the screened population, even tests with excellent sensitivity and specificity can have low PPV, generating more false-positive than true-positive results. This mathematical relationship is best illustrated by an example:
A population of 100,000 in which the prevalence of a hypothetical cancer is 1% would have 1000 persons with cancer and 99,000 without cancer. A screening test with 90% sensitivity and 90% specificity would detect 900 of the 1000 cases, but would also mislabel 9900 healthy persons (Table 3). Thus, the PPV (the proportion of persons with positive test results who actually had cancer) would be 900/10,800, or 8.3%. If the same test were performed in a population with a lower cancer prevalence of 0.1%, the PPV would fall to 0.9%, a ratio of 111 false positives for every true case of cancer detected.
Reliability (reproducibility), the ability of a test to obtain the same result when repeated, is another important consideration in the evaluation of screening tests. An accurate test with poor reliability, whether due to differences in results obtained by different individuals or laboratories (interobserver variation) or by the same observer (intraobserver variation), may produce results that vary widely from the correct value, even though the average of the results approximates the true value.
Effectiveness of Early Detection --
Even if the test accurately detects early-stage disease, one must also question whether there is any benefit to the patient in having done so. Early detection should lead to the implementation of clinical interventions that can prevent or delay progression of the disorder. Detection of the disorder is of little clinical value if the condition is not treatable. Thus, treatment efficacy is fundamental for an effective screening test. Even with the availability of an efficacious form of treatment, early detection must offer added benefit over conventional diagnosis and treatment if screening is to improve outcome. The effectiveness of a screening test is questionable if asymptomatic persons detected through screening have the same clinical outcome as those who first present with symptoms.
Lead-Time and Length Bias -
It is often very difficult to determine with certainty whether early detection truly improves outcome. This is a common problem when evaluating cancer screening tests. For most forms of cancer, five-year survival is higher for persons with early-stage disease.(4) Such data are often interpreted as evidence that early detection of cancer is effective, because death due to cancer appears to be delayed as a result of screening and early treatment. Survival data do not constitute true proof of benefit, however, because they are easily influenced by lead-time bias: Survival can appear to be lengthened when screening simply advances the time of diagnosis, lengthening the period of time between diagnosis and death without any true prolongation of life.(5)
Length bias can also result in overestimation of the effectiveness of cancer screening. This refers to the tendency of screening to detect a disproportionate number of cases of slowly progressive disease and to miss aggressive cases that, by virtue of rapid progression, are present in the population only briefly. The "window" between the time a cancer can be detected by screening and the time it will be found because of symptoms is shorter for rapidly growing cancers, so they are less likely to be found by screening. As a result, persons with aggressive malignancies will be underrepresented in the cases detected by screening, and the cases found by screening may do better than average even if the screening itself does not influence outcome. Due to this bias, the calculated survival of persons detected through screening could overestimate the actual effectiveness of screening.(5)
Assessing Population Benefits -
Although these considerations provide necessary information about the clinical effectiveness of preventive services, other factors must often be examined to obtain a broader picture of the potential health impact on the population as a whole. Interventions of only minor effectiveness in terms of relative risk may have significant impact on the population in terms of absolute risk if the target condition is common and associated with significant morbidity and mortality. Under these circumstances, a highly effective intervention (in terms of relative risk) that is applied to a small high-risk group may save fewer lives than one of only modest clinical effectiveness applied to large numbers of affected persons see (Table 4). Failure to consider these epidemiologic characteristics of the target condition can lead to misconceptions about overall effectiveness.
Potential adverse effects of interventions must also be considered in assessing overall health impact, but often these effects receive inadequate attention when effectiveness is evaluated. For example, the widely held belief that early detection of disease is beneficial leads many to advocate screening even in the absence of definitive evidence of benefit. Some may discount the clinical significance of potential adverse effects. A critical examination will often reveal that many kinds of testing, especially among ostensibly healthy persons, have potential adverse effects. Direct physical complications from a test procedure (e.g., colonic perforation during sigmoidoscopy), labeling and diagnostic errors based on test results (see above), and increased economic costs are all potential consequences of screening tests. Resources devoted to costly screening programs of uncertain effectiveness may consume time, personnel, or money needed for other more effective health care services. In this report, potential adverse effects are considered clinically relevant and are always evaluated along with potential benefits in determining whether a preventive service should be recommended.
Methodology for Reviewing Evidence -
In evaluating effectiveness, the Task Force used a systematic approach to collect evidence from published clinical research and to judge the quality of individual studies.
Literature Retrieval Methods --
Studies were obtained for review by computerized literature search of MEDLARS. Keywords used for each topic are available on request. The reference list was supplemented by citations obtained from experts and from reviews of bibliographic listings, textbooks, and other sources. This report was completed in February 1989, and studies published subsequently are not addressed.
Exclusion Criteria -
Many preventive services involve tests or procedures that are not used exclusively in the context of primary or secondary prevention. Sigmoidoscopy, for example, is also performed for purposes other than screening. Thus, studies evaluating the effectiveness of procedures or tests involving patients who are symptomatic or have a history of the target condition are not considered admissible evidence for evaluating effectiveness in asymptomatic persons. Such tests are instead considered diagnostic tests, even if they are described by investigators as "screening tests." Uncontrolled studies, comparisons between time and place (cross-cultural studies, studies with historical controls), descriptive data, and animal studies have also been excluded from the review process when evidence from randomized controlled trials, cohort studies, or case-control studies is available. Etiologic evidence, which demonstrates a causal relationship between a risk factor and a disease, was considered less persuasive than evidence from well-designed intervention studies, which measure the effectiveness of modifying the risk factor. As mentioned above, studies of preventive interventions not performed by clinicians were excluded from review.
Evaluating the Quality of the Evidence -
The methodologic quality of individual studies has received special emphasis in this report. Although all types of evidence were considered, increased weight was given to well-designed studies. Three types of study designs received special emphasis: randomized controlled trials, cohort studies, and case-control studies. In randomized controlled trials, participants are assigned in a randomized fashion to a study group (which receives the intervention) or a control group (which receives a standard treatment, which may be no intervention or a placebo). Randomization enhances the comparability of the two groups and provides a more valid basis for measuring statistical uncertainty. In this manner, differences in outcome can be attributed to the intervention rather than to other differences between groups. In a blinded trial, the investigators, the subjects, or both (double-blind study) are not told to which group subjects have been assigned, so that this knowledge will not influence their assessment of outcome. Controlled trials that are not randomized are subject to a variety of biases, including selection bias: Persons who volunteer or are assigned by investigators to study groups may differ in characteristics other than the intervention itself.
A cohort study differs from a clinical trial in that the investigators do not determine at the outset which persons receive the intervention or exposure. Rather, persons who have already been exposed and controls who have not been exposed are selected by the investigators to be followed longitudinally over time in an effort to observe differences in outcome. The Framingham Heart Study, for example, is a large ongoing cohort study providing longitudinal data on cardiovascular disease in residents of a Massachusetts community in whom potential cardiovascular risk factors were first measured over 30 years ago. Cohort studies are therefore observational, whereas clinical trials are experimental. Cohort studies are more subject to systematic bias than randomized trials because treatments, risk factors, and other covariables may be chosen by patients or physicians on the basis of important (and often unrecognized) factors that are related to outcome. It is therefore especially important for investigators to identify and correct for confounding variables, related factors that may be more directly responsible for clinical outcome than the intervention/exposure in question. For example, increased mortality among persons with low body weight can be due to the confounding variable of underlying illness.
Both cohort studies and clinical trials have the disadvantage of often requiring large sample sizes and/or many years of observation to provide adequate statistical power to measure differences in outcome. Failure to demonstrate a significant effect in such studies may be the result of statistical properties of the study design rather than a true reflection of poor clinical effectiveness. Both clinical trials and cohort studies have the advantage, however, of generally being prospective in design: the clinical outcome is not known at the beginning of the study and therefore is less likely to influence the collection of data.
Large sample sizes and lengthy follow-up periods are often unnecessary in case-control studies. This type of study differs from cohort studies and clinical trials in that the study and control groups are selected on the basis of whether they have the disease (cases) rather than whether they have been exposed to a risk factor or clinical intervention. The design is therefore retrospective, with the clinical outcome already known at the outset. In contrast to the Framingham Heart Study, a case-control study might first identify persons who have suffered myocardial infarction (cases) and those who have not (controls) and evaluate both groups to assess differences in risk factors preceding the onset of clinical disease. Principal disadvantages of this study design are that important confounding variables may be difficult to identify and adjust for, clinical outcome is already known and may influence the measurement and interpretation of data (observer bias), and participants may have difficulty in accurately recalling past medical history and previous exposures (recall bias).
Other types of study designs, such as cross-cultural studies, uncontrolled cohort studies, and case reports, provide useful data but do not generally provide strong evidence for or against effectiveness. Cross-cultural comparisons can demonstrate differences in disease rates between populations or countries, but these may be due to a variety of genetic and environmental factors other than the variable in question. Uncontrolled studies may demonstrate impressive treatment results or better outcomes than have been observed in the past (historical controls), but the absence of internal controls raises the question of whether the results would have occurred even in the absence of the intervention, perhaps as a result of other concurrent medical advances or case-selection. For further background on methodologic issues in evaluating clinical research, the reader is referred to several recent reviews.(5-7)
In summary, claims of effectiveness in published research must be interpreted with careful attention to the type of study design. Impressive findings, even if reported to be statistically significant, may be an artifact of measurement error, the manner in which participants were selected, or other design flaws rather than a reflection of a true effect on clinical outcome. In particular, p-values measure only random variability in results and do not account for bias; thus, even impressively low p-values are of little value when the data may be subject to substantial bias. Conversely, research findings suggesting ineffectiveness may result from low statistical power, inadequate follow-up, and other design limitations.
The quality of the evidence is therefore as important as the results. For these reasons, the U.S. Preventive Services Task Force established a hierarchy of evidence in which greater weight was given to those study designs that are, in general, less subject to bias and misinterpretation. The hierarchy ranked the following designs in decreasing order of importance: randomized controlled trials, nonrandomized controlled trials, cohort studies, case-control studies, comparisons between time and places, uncontrolled experiments, descriptive studies, and expert opinion. For many of the preventive services examined in this report, the Task Force assigned "evidence ratings" reflecting this hierarchy using a five-point scale (I,II-1, etc.) adapted from the scheme developed originally by the Canadian Task Force on the Periodic Health Examination (see Appendix A).(8-11)
Translating Science into Clinical Practice Recommendations -- The strength of recommendations to perform or not perform a preventive service is based on the quality of the evidence that its performance will result in more good than harm. Interventions that have been proved effective in well-designed studies or have demonstrated consistent benefit in a large number of studies of weaker design are generally recommended in this report. Interventions that have been proved to be ineffective or harmful are generally not recommended. Some preventive services are described as "clinically prudent," even though convincing evidence of effectiveness is lacking. This occurs when performance of the maneuver is not associated with significant harm or cost but has the potential of reducing the incidence of a leading cause of death or suffering in the specified group for which it is recommended. Maneuvers are often recommended for high-risk groups even though there is no additional evidence of greater effectiveness in these individuals than in the general population. This policy is based on the recognition that the absence of evidence of effectiveness does not rule out effectiveness; if, in fact, the maneuver is effective, individuals at increased risk of developing the disease are most likely to benefit.
For some preventive services no recommendation is made, because the evidence is inadequate to support a recommendation for or against performing the maneuver. For example, there is generally little scientific evidence regarding the clinical effectiveness of teaching self-examination of the breast, testes, or skin. Under these circumstances, available data are so limited that the clinician is best advised to exercise individual judgment and discretion on a case-by-case basis. Similarly, there are often inadequate data to determine the optimal frequency for performing preventive services. Rather than suggesting an arbitrary interval for testing that is not scientifically defensible, the Task Force generally recommends that clinicians use individual judgment in choosing an appropriate interval based on the patient's medical history and personal circumstances.
Some preventive services are specifically not recommended even though there is no convincing evidence that they are ineffective. This position is taken with those interventions whose potential adverse effects are of clinical concern, as well as those procedures that could generate significant increases in health care costs were they to be performed on a large proportion of the population. For example, even though further research is needed to fully evaluate the effectiveness of ultrasound screening for cancer of the prostate, ovary, or pancreas, this test is specifically not recommended by the Task Force pending the results of these studies. In addition to the potential risks of false-positive labeling, routine ultrasound screening of the general population would be costly and could divert limited resources needed for other more effective health care services. Under these circumstances, the Task Force required evidence of effectiveness before recommending widespread implementation of the preventive service.
In selected situations, even preventive services of proven effectiveness may not be recommended due to concerns about feasibility and compliance. Benefits observed under carefully controlled experimental conditions may not be generalizable to normal medical practice. That is, the preventive service may have proven efficacy but may lack effectiveness. It may be difficult for clinicians to perform the procedure in the same manner as investigators with special expertise and a standardized protocol. Patients may be less willing than research volunteers to comply with interventions that lack widespread acceptability. The cost of the procedure and other logistical considerations may make implementation of the recommendation difficult for the health care system without compromising quality or the delivery of other health care services.
For some preventive services examined by the Task Force, recommendations to perform or exclude the maneuver from the periodic health examination have been assigned a rating from a five-point (A-E) scale developed originally by the Canadian Task Force on the Periodic Health Examination (see Appendix A).(8-11) The rationale for these ratings is outlined in background papers available for review in a separate publication.(12) Background papers on selected preventive services have also been published in the Journal of the American Medical Association.(13-20) For the majority of topics examined in this report, which were not examined in this manner, scientific reviews and evaluations were conducted under Task Force supervision by scientific staff who were recruited by the Task Force and based at the Office of Disease Prevention and Health Promotion in Washington, D.C.
Outside Review Process -
The Task Force recommendations have been reviewed by over 300 experts in Government health agencies, academic medical centers, and medical organizations in the United States, Canada, and the United Kingdom. The report has received extensive review by representatives of the U.S. Public Health Service. Recommendations were modified on the basis of reviewer comments if the reviewer identified relevant studies not examined in the report, misinterpretations of findings, or other issues deserving revision within the constraints of the Task Force methodology. The format of this report was designed in consultation with representatives of medical specialty organizations, including the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Preventive Medicine, the American Dental Association, and the American Osteopathic Association.(21)
Recommendations appearing in this report are intended as guidelines, providing clinicians with information on the proven effectiveness of preventive services in published clinical research. Recommendations for or against performing these maneuvers should not be interpreted as standards of care but rather as statements regarding the quality of the supporting scientific evidence. Clinicians with limited time can use this information to help select the preventive services most likely to benefit patients in selected risk categories. However, sound clinical decision making requires careful consideration of many variables; the science base must be examined along with other important aspects of the medical history and the clinical setting. Departure from these recommendations by clinicians familiar with a patient's individual circumstances is often appropriate and should not necessarily be interpreted by patients or others as compromising quality of care.
References
1. Battista RN, Fletcher SW. Making recommendations on preventive practices: methodological issues. Am J Prev Med Suppl 1988; 4:5367. 2. Lefebvre RC, Hursey KG, Carleton RA. Labeling of participants in high blood pressure screening programs: implications for blood cholesterol screenings. Arch Intern Med 1988; 148:1993-7.
3. MacDonald LA, Sackett DL, Haynes RB, et al. Labelling in hypertension: a review of the behavioral and psychological consequences. J Chron Dis 1984; 37:933-42.
4. American Cancer Society. Cancer statistics, 1989. CA 1989; 39:332. 5. Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology. Boston: Little, Brown, 1985.
6. Fletcher RH, Fletcher SW, Wagner EH. Clinical epidemiology: the essentials. Baltimore, Md.: Williams and Wilkins, 1988.
7. Bailar JC III, Mosteller F, eds. Medical uses of statistics. Waltham, Mass.: NEJM Books, 1986.
8. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-254.
9. Idem. The periodic health examination. 1984 update. Can Med Assoc J 1984; 130: 1278-85.
10.Idem. The periodic health examination. 1986 update. Can Med Assoc J 1986; 134: 721-9.
11.Idem. The periodic health examination. 1988 update. Can Med Assoc J 1988; 138: 617-26.
12.Lawrence RS, Goldboom RB, eds. Preventing disease: beyond the rhetoric. New York: Springer-Verlag (in press).
13.O'Malley MS, Fletcher SW. Screening for breast cancer with breast self- examination: a critical review. JAMA 1987; 257:2197-203.
14.LaForce FM. Immunizations, immunoprophylaxis, and chemoprophylaxis to prevent selected infections. JAMA 1987; 257:2464-70.
15.Horsburgh CR, Douglas JM, LaForce FM. Preventive strategies in sexually transmitted diseases for the primary care physician. JAMA 1987; 258:815-21.
16.Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988; 259:2882-9.
17.Polen MR, Friedman GD. Automobile injury: selected risk factors and prevention in the health care setting. JAMA 1988; 259:76-80. 18.Knight KK, Fielding JE, Battista RN. Occult blood screening for colorectal cancer. JAMA 1989; 261:587-93.
19.Selby JV, Friedman GD. Sigmoidoscopy in the periodic health examination. JAMA 1989; 261:595-602.
20.Harris SS, Caspersen CJ, DeFriese GH, et al. Physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting: report for the US Preventive Services Task Force. JAMA 1989; 261:3590-8.
21.Centers for Disease Control. Chronic disease control activities of medical and dental organizations. MMWR 1988; 37:325-8.
The Periodic Health Examination: Age-Specific Charts
The periodic health visit is an important opportunity for the delivery of clinical preventive services. Determining the specific preventive services that are most appropriate for inclusion in the periodic health examination has been one of the principal objectives of the U.S. Preventive Services Task Force project. The process by which these determinations were made is discussed in detail. This chapter explores the recommended content of the periodic health examination. It includes a series of eight tables that state the specific preventive services that should be considered for patients in different age groups.The Task Force judged it especially important to tailor the content of the periodic examination to the individual needs of the patient and to emphasize those preventive services that have proved to be effective in properly conducted studies. This approach is based on the recognition that the leading causes of illness and injury in an individual patient depend on age, sex, and other risk factors. The clinician whose time with patients is limited is therefore best advised to target preventive measures toward those conditions most likely to significantly influence the health and well-being of the patient being examined. The two most important factors to consider are the leading causes of morbidity and mortality in the patient and the potential effectiveness of clinical interventions in altering the natural history of those diseases.
Leading causes of morbidity and mortality are essential to consider with each patent if the clinician is to determine which conditions are most important to prevent Failure to do so can lead to misplaced priorities when performing the periodic health examination. For example, a clinician wishing to include a preventive measure during the few remaining minutes of an office visit with an adolescent male might consider teaching the patient how to perform testicular self-examination An estimated 350 persons will die from testicular cancer in the United States during 1989 and it is believed that early detection is an important means of improving survival.(1) However, a teenage male is considerably more likely to die from an injury than from cancer or any other disease. Of the 39,929 deaths among young persons (aged 15-24 years)in the United States during 1986, 19,975 were due to injuries (15,227 due to motor vehicles crashes), 5522 were due to homicides, and 5120 were the result of suicide.(2) All forms of cancer combined accounted for only 2115 deaths in this age group.(2) It seems likely on the basis of mortality data alone that a few minutes with an adolescent might be more productively spent by discussing the prevention of unintentional and intentional injuries. Leading causes of morbidity, such as unintended pregnancy, depression, and drug abuse, are also important target conditions.
Clinical efforts directed toward these important conditions may be of limited however, if the preventive intervention does not result in improved outcome. Thus, the second major consideration in setting priorities is effectiveness. Although homicide and suicide are leading causes of death among adolescents, the effectiveness of efforts by clinicians to prevent deaths from intentional injuries has not been established. However, measures to reduce the risk of motor vehicle injuries, the leading cause of death in this age group, are well established Proper use of safety belts has proved to reduce the risk of injury and death from motor vehicle crashes by as much as 40-60%.(3,4) Alcohol intoxication is associated with half of all injury fatalities.(5) With one out of three deaths among young persons occurring in motor vehicle crashes,(2) the busy clinician seeing young patients is best advised to direct attention to the use of safety belts and the dangers of driving while under the influence of alcohol.
Age is only one of many risk factors the clinician must consider in designing an appropriate periodic health examination. Among persons in special high-risk groups, the leading causes of morbidity and mortality may differ considerably from other individuals of the same age and sex. For example, although sexually transmitted diseases and unintended pregnancy are unlikely problems for sexually, abstinent teenagers, they are important sources of morbidity among those who are sexually active. One out of four cases of gonorrhea (195,274 cases) reported in the United States during 1987 occurred among persons aged 10-19.(7) Intravenous drug use is also uncommon in the general population, but among individuals with this history, acquired immunodeficiencY syndrome (AIDS) is the leading cause of death.8 Thus, the most important preventive interventions in the period health examination of an intravenous drug user are counseling to obtain treatment for chemical dependency and education about measures to prevent transmission of infectious disease. These and other methodologic issues in establishing priorities for preforming preventive Services are discussed in greater detail in (see Methodology).
The differences in priorities among individuals in different age groups and risk categories and the effectiveness of some preventive services in only certain populations suggests that a uniform periodic health examination cannot be recommended for all persons. The reader will note that recommendations throughout this report are targeted toward individuals who meet specific risk factor criteria only rarely do they apply universally to all patients. While it is therefore difficult design a periodic health examination that accounts fully for differences among patients, the eight tables that follow identify those recommended preventive services that should be considered for patients in specific age groups.
The reader is urged to refer to appropriate chapters in this report to obtain more detailed information about the proper indications for specific preventive service than can be provided in the tables. The review of evidence in the text also provide the scientific rationale for the recommendations, which are based on a system methodology (see Methodology). The reader can also compare the Task Force recommendations with those of major organizations and Government agencies, who are listed in each chapter under the heading Recommendations of Others. In addition, all chapters include a detailed Clinical Intervention section that provide concise information for the clinician on currently recommended techniques, dos-ages, and other specifics for performing recommended preventive services.
The preventive services examined in this report and appearing in Tables 5-12 have been carefully defined. They include only those preventive services that would be performed by clinicians on asymptomatic persons in the context of routine health care (see Methodology). Preventive measures involving persons with sign symptoms of disease and those performed outside the clinical setting are within the scope of this report or its recommendations.
The tables are not intended to be a complete list of all preventive services should be offered during the periodic health examination. Rather, these recommendations encompass only those preventive services that have been examined in the report and that have been shown to have satisfactory evidence of clinical not effectiveness, based on the methodology discussed in the Methodology Chapter. Since the evaluations were defined by specific preventive services, general procedures such as are the medical history and the physical examination were not examined in their entirety.
The interventions listed are therefore not exhaustive. The periodic health examination performed by most pediatricians, for example, includes a number of maneuvers that were not examined by the Task Force, such as screening for belts developmental disorders and anticipatory guidance, The interested reader should refer to the recommendations of other groups for luther information on such topics. Similarly, recommendations relating to preventive services during pregnancy should not be interpreted as comprehensive guidelines for prenatal care.
Recommendations by the Task Force against performing certain preventive services are not intended to be unconditional. The clinician may judge such maneuvers to be appropriate in light of the medical history of the patient, local standards of care, or other individual circumstances.
Many of the preventive services appearing in Tables 5-12 are recommended Intra only for members of high-risk groups and are not considered appropriate in the routine examination of all persons in the age group. The specific risk groups for which the maneuver is considered appropriate are identified by an annotated high-risk (HR) code accompanying each table. The reader should refer to appropriate chapters in the report for more detailed guidelines to help identify individuals at increased risk. Risk factors that are especially important for clinicians to identify at an early stage but that are not considered appropriate for routine screening are listed under the heading Remain Alert For. Many of the disorders appearing undo risk this heading are often overlooked by clinicians due to failure to recognize suggestive signs or symptoms or the importance of early identification.
A frequency schedule for periodic health visits is recommended in each table. These intervals are considered clinically prudent; however, scientific data are lacking to determine the optimal frequency for such visits. Clinicians should exercise discretion in selecting an appropriate schedule, especially for patients with abnormal signs or symptoms and those with chronic illness. The preventive services listed in each table are not necessarily recommended at every periodic visit. For example, although thyroid function tests may be clinically prudent in more elderly women, they are not recommended annually even though periodic visits in this age group are recommended once a year.
Although the preventive services listed in Tables 5-12 can serve as the basis for Designing periodic checkups devoted entirely to disease prevention, they may also be performed during visits for other reasons (e.g., illness visits, chronic disease checkups) when indicated. For patients with limited access to care, the illness visit In may provide the only realistic opportunity for the clinician to discuss prevent on. It is recognized that busy clinicians may not be able to perform all recommended Preventive services during a single clinical encounter. Indeed, it is not clear that such a grouping is either necessary or clinically effective. Patients suffering from an acute illness or injury may not be receptive to some preventive interventions. The clinician must therefore use discretion in selecting appropriate ate preventive services from these lists and may wish to give special emphasis to those preventive services aimed at the leading causes of illness and disability in the age group. Age-specific leading causes of death are listed in each table to aid the clinician in making this assessment. Recommended preventive services that cannot be Performed by the clinician could be scheduled for a later health visit.
Immunizations appearing in Tables 5-12 are those recommended on a routine basis and do not apply to persons with special exposures to infected individuals. The reader is referred to the Postexposure Prophylaxis Chapter for detailed guidelines on immunization if such circumstances.
The Periodic Health Examination: Age-Specific Charts
The periodic health visit is an important opportunity for the delivery of clinical preventive services. Determining the specific preventive services that are most appropriate for inclusion in the periodic health examination has been one of the principal objectives of the U.S. Preventive Services Task Force project. The process by which these determinations were made is discussed in detail. This chapter explores the recommended content of the periodic health examination. It includes a series of eight tables that state the specific preventive services that should be considered for patients in different age groups.The Task Force judged it especially important to tailor the content of the periodic examination to the individual needs of the patient and to emphasize those preventive services that have proved to be effective in properly conducted studies. This approach is based on the recognition that the leading causes of illness and injury in an individual patient depend on age, sex, and other risk factors. The clinician whose time with patients is limited is therefore best advised to target preventive measures toward those conditions most likely to significantly influence the health and well-being of the patient being examined. The two most important factors to consider are the leading causes of morbidity and mortality in the patient and the potential effectiveness of clinical interventions in altering the natural history of those diseases.
Leading causes of morbidity and mortality are essential to consider with each patent if the clinician is to determine which conditions are most important to prevent Failure to do so can lead to misplaced priorities when performing the periodic health examination. For example, a clinician wishing to include a preventive measure during the few remaining minutes of an office visit with an adolescent male might consider teaching the patient how to perform testicular self-examination An estimated 350 persons will die from testicular cancer in the United States during 1989 and it is believed that early detection is an important means of improving survival.(1) However, a teenage male is considerably more likely to die from an injury than from cancer or any other disease. Of the 39,929 deaths among young persons (aged 15-24 years)in the United States during 1986, 19,975 were due to injuries (15,227 due to motor vehicles crashes), 5522 were due to homicides, and 5120 were the result of suicide.(2) All forms of cancer combined accounted for only 2115 deaths in this age group.(2) It
Table 5: Leading Causes of Death, Birth to 18 Months
(Table 5)Table 6: Leading Causes of Death, Ages 2-6
(Table 6)Table 7:Leading Causes of Death, Ages 7-12
(Table 7)Table 8:Leading Causes of Death, Ages 13-18
(Table 8)Table 9:Leading Causes of Death, Ages 19-39
(Table 9)Table 10: Leading Causes of Death, Ages 40 -64
(Table 10)Table 11: Leading Causes of Death, Ages 65 and Over
(Table 11)Table 12: Pregnant Women
(Table 12)REFERENCES
1. American Cancer Society. Cancer statistics, 1989. CA 1989; 39:332. 2. National Center for Health Statistics. Advance report of final morality statistics, 1986. Monthly Vital Statistics Report, vol. 37, no. 6. Hyattsville, Md.: Public Health Service, 1988. (Publication no. DHHS (PHS) 88-1120.)
3. Department of Transportation. Final regulatory impact assessment on amendments to Federal Motor Vehicle Safety Standard 208, Front Seat Occupant Protection. Washington, D.C.: Department of Transportation, 1984. (Publication no. DOT HS 806-572.)
4. Campbell BJ. Safety belt injury reduction related to crash severity and front seated position. J Trauma 1987; 27:733-9.
5. Baker SP, O'Neill B, Karpf R. The injury fact book. Lexington, Mass.: DC Heath and Company, 1984.
6. Waller JA. Injury control: a guide to causes and prevention of trauma. Lexington, Mass.: DC Heath and Company, 1985.
7. Centers for Disease Control. Summary of notifiable diseases, United States, 1987. MMWR 1988; 36:10.
8. Curran JW, Jaffe HW, Hardy AM, et al. Epidemiology of HIV infection and AIDS in the United States. Science 1988; 239:610-6.
9. American Academy of Pediatrics. Guidelines for health supervision. Elk Grove Village.III.: American Academy of Pediatrics, 1985. 10.Idem. Recommendations for preventive pediatric health care. Committee on Practice and Ambulatory Medicine. Elk Grove Village, III.:American Academy of Pediatrics, 1987.
Recommendations for Patient Education and Counseling
Empirical research and clinical experience yield certain principles that clinicians can use to induce behavior change among patients. Attention to these key concepts should enhance the effectiveness of physician counseling concerning all behavioral changes recommended in this report.1. Develop a therapeutic alliance. See yourself as an expert consultant available to help patients who remain in control of their own health choices. This perspective facilitates development of a therapeutic alliance in which health is maintained or achieved through a provider-patient partnership.(1,2) Help motivate patients who smoke, abuse alcohol and other drugs, or do not exercise to change these behaviors. Assist them in acquiring the necessary attitudes and skills to succeed in their attempts.
2. Counsel all patients. Most patients are eager for health information and guidance and generally want more than physicians provide.(3) Whites tend to receive more information than blacks and Hispanics,(4,5) and middle class patients tend to receive more than working class patients.(6) Physicians tend to talk more with patients who pose more questions, but those who are quieter are often in greater need of education.(7) Make a concerted effort to respond to the educational needs of all your patients in ways appropriate to their age, race, sex, socioeconomic status, and interpersonal skills.
3. Ensure that patients understand the relationship between behavior and health. Inquire about what your patients already know or believe about the relationship between risk factors and health status. Do not assume that patients understand the health effects of smoking, lack of exercise, poor nutrition, and other lifestyle factors. Explain in simple terms the idea that certain factors can increase the risk of disease and that combinations of factors can sometimes work to