Preventive Services That Providers and Care Systems Must Deliver (Based on Best Evidence) (Level I)
Level I preventive services are worthy of attention at every visit. Busy clinicians cannot deliver this many services in any single visit. However, with systems in place to track whether or not patients are up-to-date with the high-priority preventive services recommended for their age group, clinicians can offer the high priority services as opportunities present.
Aspirin Chemoprophylaxis Counseling
Services
Aspirin prophylaxis should be discussed with postmenopausal women, men above the age of 40, and younger men and women who are at increased risk for coronary heart disease (CHD) because of tobacco use, dyslipidemia, hypertension, diabetes, or family history of premature CHD.
Although the U.S. Preventive Services Task Force (USPSTF) found there is fair evidence that higher doses of aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) used over longer periods of time may reduce the incidence of colorectal cancer, the task force concludes the harms outweigh the benefits and recommends against routine use of aspirin and NSAIDs for the primary prevention of colorectal cancer in average risk individuals.
Efficacy
U.S. Preventive Services Task Force guideline recommends a discussion of aspirin therapy for primary prevention of myocardial infarction with patients at risk of coronary heart disease (CHD).
Estimates of the magnitude of benefits and harms of aspirin therapy vary with an individual's risk for CHD. Estimates of benefits and harms of aspirin therapy to 1,000 individuals are as follows: CHD events avoided, 1-20; major gastrointestinal bleeding events caused, 2-4; hemorrhagic strokes caused, 0-2.
Using a risk calculator provides a more accurate estimate of cardiovascular risk. Prior to publication of the nurses' health study results, the USPSTF concluded that the balance of benefits and harms from aspirin chemoprophylaxis is most favorable in patients at high risk for CHD (five-year risk greater than or equal to 3%), including all postmenopausal women and all men over the age 40.
The optimum dosage of aspirin therapy is not known. Doses of 81 mg per day appear as effective as higher doses.
Evidence supporting this recommendation is of classes: A, M, R
Breast Cancer Screening
Services
Screening mammogram every 1 to 2 years is recommended for women age 50 to 75 years.
Mammograms may be performed at the mutual consent of the patient and provider in women over the age of 75.
Women age 40 to 49 years with high risk factors should initiate annual screening. High risk factors include:
- Previous breast biopsy demonstrating atypical hyperplasia
- Family history of breast cancer in the patient's mother, sister, or daughter
- Past personal history of breast cancer
The evidence for mortality reduction for low-risk women of this age group is less clear.
Efficacy
The most important tool in the early detection of breast cancer is screening mammography. The USPSTF updated its recommendation in 2002, finding "fair evidence that mammography screening every 12 to 33 months significantly reduces mortality from breast cancer." They concluded that the evidence is strongest for women aged 50 to 69 and that the clinical trials reveal no clear difference due to interval within the 12 to 33-month time range. Their recommendation is for "mammography, with or without clinical breast exam (CBE) every one to two years for women aged 40 and older." This extension to the 40 to 49 year old group has been controversial.
References/Related Guidelines
See the NGC summary of the ICSI guideline Diagnosis of Breast Disease.
Evidence supporting this recommendation is of classes: M, R
Calcium Chemoprophylaxis Counseling
Services
Counsel adult women to use calcium supplements to prevent fractures.
Efficacy
Adequate calcium intake from food sources and supplements promotes bone health. When food sources do not provide enough calcium, supplements can be used to meet this goal. Bioavailability of calcium in food sources and supplements is a factor in achieving daily calcium recommendations. Calcium supplement labels should indicate lead testing.
Daily elemental calcium recommendations for healthy individuals from diet and supplement include:
19 to 50 years - 1,000 milligrams
Over 50 years - 1,200 milligrams
Maximum limit - 2,500 milligrams
However, for people with established osteoporosis, glucocorticoid therapy, pregnant or nursing women, or persons over the age of 65, it may be more appropriate to recommend 1,500 milligrams.
Both low fractional calcium absorption and low dietary calcium intake have been associated with increased fracture risk. Since fractional calcium absorption is affected by multiple factors and decreases with age, adequate lifetime dietary calcium is an important recommendation for bone health.
References/Related Guidelines
See the NGC summary of the ICSI guideline Diagnosis and Treatment of Osteoporosis.
Evidence supporting this recommendation is of class: R
Cervical Cancer Screening
Services
All women should be screened for cervical cancer beginning at age 21 or three years after initiating sexual intercourse, whichever is earlier. Screening should be performed every three years after three consecutive normal Pap smears over five years.
For women who have had a total hysterectomy for benign disease, and who do not have a history of cervical intraepithelial neoplasia (CIN) 2/3, Pap smears are no longer indicated.
Currently there is no evidence to support more frequent Pap smears during the prenatal/postpartum period. In fact, hormone levels up to six weeks postpartum are often not yet back to normal, which can influence Pap smear results.
After age 65, there is no clear evidence for continuing Pap smears in women who have had previous normal screening. Women age 65 and older who have a new sexual partner should resume routine screening.
Human papillomavirus (HPV) testing may be used as an adjunct to Pap smear screening to help minimize unnecessary colposcopies and other interventions.
Women who have had dysplasia on prior Pap smears should continue with annual screening for five years after the last dysplastic pap smear; after that, they need only every-three-year screening.
Women with a history of CIN 2/3 and a subsequent total hysterectomy for benign disease may discontinue Pap smears after three consecutive normal tests within a ten-year period.
References/Related Guidelines
See the NGC summary of the ICSI guideline Initial Management of Abnormal Cervical Cytology (Pap Smear) and HPV Testing.
Evidence supporting this recommendation is of classes: C, M, R
Chlamydia Screening
Services
Routine screening for chlamydia is recommended for all sexually active women aged 25 years and younger and older women at increased risk for infection.
Risk factors include:
- Having new or multiple sex partners
- Having prior history of a sexually transmitted infection (STI)
- Not using condoms consistently and correctly
Refer to the original guideline document for information on burden of suffering from chlamydia.
Efficacy
The most efficacious means of reducing the risk of acquiring sexually transmitted infections through sexual contact is either abstinence from sexual relations or maintenance of a mutually monogamous sexual relationship with an uninfected partner. Condoms have been shown in the laboratory to prevent transmission of chlamydia trachomatis, herpes simplex virus, trichomonas, cytomegalovirus and human immunodeficiency virus (HIV). Even under optimal conditions, however, condoms are not always efficacious in preventing transmission. Condom failures occur at an estimated rate of 10% to 15% either as a result of product failure or as a result of incorrect or inconsistent use.
Evidence supporting this recommendation is of classes: A, R
Colorectal Cancer Screening
Key Points:
- Patients between the ages of 50 and 80, or age 45 to 80 for African Americans, should be screened for colorectal cancer at appropriate intervals as determined by whichever screening method is chosen.
- Several different screening methods (fecal occult blood testing [FOBT] annually, combination of 60 cm flexible sigmoidoscopy every five years and FOBT annually, 60 cm flexible sigmoidoscopy every five years, total colon evaluation, or a combination of methods) are all effective.
- The screening method utilized should be determined by joint decision making by the patient and provider.
Services
The ICSI Colorectal Cancer Screening guideline (see NGC summary) recommends screening for colorectal cancer in average risk patients 50 to 80 years of age, or 45 to 80 for African Americans. While the best data available support screening between ages 50 and 80, otherwise healthy individuals over the age of 80 may be candidates for screening if their presumed life expectancy is eight or more years.
Average-risk patients are considered to be individuals with no personal history of polyps or colorectal cancer, no family history of colorectal cancer (one first order relative diagnosed before age 60 or two first order relatives diagnosed at any age), and no family history of adenomatous polyps (one first order relative diagnosed before age 60).
Patients with a history of prior adenomatous polyp with villous component or any adenomatous polyp greater than 10 mm, long-standing chronic ulcerative colitis, or a family history of familial polyposis coli or non-polyposis hereditary colorectal cancer are considered to be at high-risk for developing colorectal cancer. These individuals require colonoscopic surveillance every three to five years and fall outside the scope of this guideline.
There is no single "best" test for colorectal cancer screening and the final choice is often best made jointly, based on the clinical judgment of a well informed provider and the preferences of a well informed patient.
Efficacy
The guideline summarizes the evidence for the effectiveness of the various screening tests commonly used for colorectal cancer screening.
Both annual FOBT and 60 cm flexible sigmoidoscopy performed every five years have proven benefit in detecting colorectal cancer and adenomatous polyps. The guideline workgroup did not reach absolute consensus as to which screening test is preferable, but does advocate screening by one or both tests. The high false positive rate of FOBT, the inability of flexible sigmoidoscopy to visualize the entire colon, and at least one report that one time combined screening failed to detect 24% of advanced colonic neoplasia, were all noted.
If in the judgment of the provider an examination of the whole colon and rectum is desired, this can be accomplished by either colonoscopy, flexible sigmoidoscopy combined with fluoroscopic barium enema, or double contrast barium enema (DCBE). In some clinical situations computed tomography (CT) colonography may be reasonable. If the sigmoid colon is not well visualized on DCBE, a flexible sigmoidoscopy should be obtained. The interval between exams with flexible sigmoidoscopy alone or combined with fluoroscopic barium enema and between DCBE is five years. The interval between exams with colonoscopy is 10 years. At this time no clear recommendations can be made regarding the interval between CT colonography exams.
CT colonography is superior to FOBT, flexible sigmoidoscopy, and barium enema, and is a viable alternative to colonoscopy for colorectal cancer screening. Its use is limited by cost and reimbursement issues, the high number of extracolonic findings requiring further evaluation, and other issues. CT colonoscopy may be indicated in settings where the proximal colon cannot be examined by conventional colonoscopy, or in patients where colonoscopy is relatively contraindicated (e.g., anticoagulation).
References/Related Guidelines
See the NGC summary of the ICSI guideline Colorectal Cancer Screening.
Evidence supporting this recommendation is of class: R
Hypertension Screening
Key Points:
- Check blood pressure (BP) at least every two years.
- Promote a healthy lifestyle to optimize blood pressure control.
- Target blood pressure goal in context of additional cardiovascular risk factors.
Services
To detect and monitor hypertension, blood pressure should be measured at least every two years for adults with BP less than 120/80 and every year if BP is 120-139/80-89 mm Hg. Higher blood pressures should be confirmed and managed per protocol. As a practical matter, this standard may be most reliably implemented if blood pressure is measured at every patient visit.
Efficacy
Periodic Screening in Adults at Patient Visits
Hypertension is an important public health problem that affects 25 to 30% of adult Americans. Hypertension is a major risk factor for ischemic heart disease, left ventricular hypertrophy, renal failure, stroke, and dementia. Conversely, blood pressure control is correlated with a reduction in incidence of myocardial infarctions, strokes, and heart failure.
Standardized Blood Pressure Measurement
Accurate, reproducible blood pressure measurement is necessary to ensure correct blood pressure classification and to allow valid comparisons among serial pressure recordings.
Blood Pressure Screening Classification
The relationship between blood pressure measurement and vascular risk is continuous and graded. The risk of cardiovascular disease doubles with each increment of 20/10 above 115/75. Thus the classification of adult blood pressure is somewhat arbitrary.
Confirming Elevation/Education and Risk Factor Assessment
A proposed follow-up schedule based on the initial blood pressure level as well as diabetes, cardiovascular or renal disease and risk factors is noted in the Hypertension Diagnosis and Treatment guideline (see NGC summary). Recommend blood pressure confirmation and follow-up within two months if the blood pressure is 140 to 159/90 to 94. Recommend blood pressure confirmation and follow-up within one month if the blood pressure is greater than 160/100.
Counseling Messages
- If BP is greater than 120/80, it needs to be confirmed and evaluated in the context of the patient's risk factors.
While the evidence is limited, clinicians may consider encouraging patients to modify lifestyle to promote blood pressure control, especially in the presence of additional risk factors for vascular disease, such as dyslipidemia or diabetes mellitus. Important modifications include weight loss if overweight, limiting alcohol use, nicotine abstinence, increased physical activity and reduced dietary sodium and increased potassium and calcium intake.
References/Related Guidelines
See the NGC summary of the ICSI guideline Hypertension Diagnosis and Treatment.
Evidence supporting this recommendation is of classes: B, C, M, R
Influenza Immunization
Services
Provide immunization annually throughout entire flu season for individuals age 50 and older, those at high risk, and all persons who wish to decrease the likelihood of contracting influenza.
References/Related Guidelines
See the NGC summary of the ICSI guideline Immunizations.
Evidence supporting this recommendation is of class: R
Lipid Screening
Key Points:
- Screen men over age 34 and women over age 44 with serum cholesterol fractionation measurement every five years.
- The decision to screen men aged 20 to 34, and women aged 20 to 44, should be based on risk for coronary heart disease (CHD) and the individual preferences of the patient.
- Patients with low-density lipoprotein (LDL)-cholesterol 130 mg/dL or more, or high-density lipoprotein (HDL)-cholesterol less than 40 mg/dL, who have a triglyceride level of 200 mg/dL or more should follow treatment recommendations as outlined in the NGC summary of the ICSI guideline Lipid Management in Adults.
Services and Counseling Messages
A fasting cholesterol fractionation (total cholesterol, calculated LDL-cholesterol, HDL-cholesterol and triglyceride) is recommended for men over age 34 and women over age 44 every five years.
If patient is not fasting and probability of a return visit is low, consider checking total cholesterol and HDL-cholesterol. If available, also consider measuring direct LDL-cholesterol.
Based on risk assessment, patients and providers should discuss the issues surrounding lipid screening with men between the ages of 20 and 34 years and women between the ages of 20 and 44 years. A specific example would be the need to screen those men aged 20 to 34 years and women aged 20 to 44 years with first-degree relatives with total cholesterol greater than 300 or history of premature CHD.
Individuals with total cholesterol less than 200, LDL less than 130, triglyceride less than 200, and HDL of 40 or above have a desirable cholesterol level and should be advised to repeat cholesterol fractionation in five years.
Individuals with total cholesterol greater than or equal to 200, LDL greater than or equal to 130, triglyceride greater than or equal to 200, and HDL less than 40 may be at higher risk of vascular disease and these patients should follow treatment recommendations as outlined in the NGC summary of the ICSI guideline Lipid Management in Adults.
Patients whose screening recommendations would be different include those who:
- Have histories of CHD, cerebrovascular disease (CVD), peripheral vascular disease (PVD), diabetes mellitus (DM), metabolic syndrome, or who are being case managed for dyslipidemia. Their disease management will involve a more aggressive approach to lipid monitoring.
- Have health status or life expectancy which would not be affected by knowledge of their lipid status (e.g., those with comorbid conditions such as terminal cancer).
- Are in circumstances where cholesterol levels may not represent their usual levels. These situations include acute illness, hospitalization, unintended weight loss, pregnancy, or lactation within the previous three months. Screening should be delayed under these circumstances.
Lipid testing is recommended because elevated LDL, elevated triglycerides, or/and low HDL are important risk factors for CHD. Treatment of these risk factors is readily available and significantly decreases the risk for CHD.
Efficacy
There is good evidence that lipid measurements can identify in men greater than age 34 years and women greater than age 44 years individuals at increased risk of CHD and good evidence that treatment substantially reduces the incidence of CHD.
No clinical trials address the treatment of dyslipidemia among men aged 20 to 34 years and among women aged 20 to 44 years. Screening should be individualized for patients in these age groups.
Fractionated cholesterol is the most effective screening test for dyslipidemia because elevated LDL and triglycerides or low HDL are risk factors for vascular disease.
Some patients should not be offered lipid screening as outlined in this guideline. It is well recognized that cholesterol interpretation depends on the presence of other risk factors for large vessel disease. Patients with diabetes mellitus are at high risk for large vessel disease and for that reason should undergo aggressive lipid management. Patients with CAD, PVD, and/or CVD should also be aggressively managed for dyslipidemia.
References/Related Guidelines
See the NGC summary of the ICSI guideline Lipid Management in Adults.
Evidence supporting this recommendation is of classes: A, B, C, M, R
Pneumococcal Immunization
Services
Immunize high-risk groups once. Re-immunize those at risk of losing immunity once after five years. Immunize at 65 if not done previously. Re-immunize once if first received was greater than five years ago and before age 65 or an appropriate immunocompromising condition is present.
References/Related Guidelines
See the NGC summary of the ICSI guideline Immunizations
Evidence supporting this recommendation is of class: R
Problem Drinking Screening and Brief Counseling
Services
The goal is to identify those with risky or hazardous drinking as well as those who have carried that behavior to the point of meeting criteria for dependence, and then provide a brief intervention. In the U.S., risky/hazardous drinking is defined as the number of standard drinks (12 oz. beer, 1 glass of wine, or mixed drink) in a given time period:
- Women: greater than 7 drinks/week or greater than 3 drinks/occasion
- Men: greater than 14 drinks/week or greater than 4 drinks/occasion
This can be done by having the clinician or (preferably) rooming nurse simply ask about the quantity drunk, using a simple questionnaire with the same questions on it, or using a formal validated screening questionnaire, of which the AUDIT is best (10 questions, created by the World Health Organization [WHO], extensively validated, and included in Appendix B, "Counseling and Education Tools: Problem Drinking" of the original guideline document).
Other questionnaires, especially the 4 question CAGE (also in Appendix B of the original guideline document) are primarily designed to identify those with dependence, so don't include questions about the quantity/frequency.
Efficacy
The U.S. Preventive Services Task Force in 2004 "found good evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality." It also "found good evidence that brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer." It gave these recommendations a B rating.
Counseling Messages
Brief counseling should follow the 5A model (a variation on tobacco intervention guideline):
- Assess current and historical use of alcohol.
- Advise patients to reduce use to moderate levels.
- Agree on individual goals for reduction or abstinence.
- Assist with motivation, skills, and supports.
- Arrange follow-up support and repeated counseling, including referral if needed.
Other messages that may be of value include:
- Advise all females of childbearing age of the harmful effects of alcohol on a fetus and the need for cessation during pregnancy.
- Reinforce not drinking and driving.
- Advise patients not to ride with someone under the influence of alcohol and to prevent him or her from driving.
References/Related Guidelines
See Appendix B, "Counseling and Education Tools: Problem Drinking" in the original guideline document for the CAGE Questionnaire and AUDIT Structured Interview.
Evidence supporting this recommendation is of classes: M, R
Tobacco Use Screening and Brief Intervention
Services
Establish tobacco use status for all patients. All forms of tobacco should be screened. Provide ongoing cessation services to all tobacco users at every opportunity.
Establish secondhand smoke exposure status for all patients. Advise all patients exposed to secondhand smoke that exposure is harmful. Encourage a smoke-free living and working environment for patients, and assist the exposed patient to communicate with other household members about decreasing smoke in their house. Encourage the patient to support smoking cessation efforts among other household members who use tobacco.
Efficacy
Tobacco use is the single most preventable cause of death and disease in our society. There is good evidence that clinical-based interventions are effective. Tobacco cessation services are most effective when offered on a regular basis to all patients who use tobacco. The key components of successful tobacco cessation interventions are:
- Ask about tobacco use and smoke exposure at every opportunity.
- Advise all users to quit.
- Assess willingness to make a quit effort.
- Assist users who are willing to make a quit attempt.
- Arrange follow-up.
These components are best carried out when the entire office staff is organized to provide these services.
Three treatment elements are effective for tobacco cessation intervention: pharmacotherapy, social support for cessation, and skills training/problem-solving. The more intense the treatment, the more effective it is in achieving long-term abstinence from tobacco.
While readiness stage intervention is commonly used, evidence does not strongly support it.
The recommended intervention includes promoting a smoke-free living environment because secondhand smoke is a major contributor to tobacco-related health problems.
Structured physician clinical-based smoking cessation counseling is more effective than usual care in reducing smoking rates. The addition of telephone-based counseling may result in further improvements in cessation. [Conclusion Grade II: See Conclusion Grading Worksheet A -- Annotation #4 (Smoking Cessation Counseling) in the original guideline document]
Counseling Messages
- Advise tobacco users to quit.
- Assess user's willingness to make a quit attempt.
- Provide counseling depending on readiness-to-quit stage. Provide a motivational intervention if the user is not ready to make a quit effort.
- Assist in quitting if ready to make a quit effort. Negotiate a quit date. Counsel to support cessation and build abstinence skills. Discuss pharmacotherapy. Offer phone line for more assistance.
- Arrange follow-up.
Evidence supporting this recommendation is of class: R
Vision Screening
Services
Objective vision testing (Snellen chart) for asymptomatic patients is recommended only for elderly adults.
Efficacy
Vision screening has been recommended for elderly adults by the USPSTF based upon separate evidence of high prevalence of under-corrected impairments, the accuracy of screening tests, the effectiveness of eye glasses, and the willingness of some individuals to follow-through with additional screening and purchase of eye glasses. No studies have directly demonstrated a relationship between vision screening and improved usual corrected vision, improved quality of life, or activities of daily living.
A review of epidemiologic studies conducted in the United States, United Kingdom, and Australia concluded that the prevalence of under-corrected visual impairment is about 10% between the ages of 65 and 75 and 20% above the age of 75. These summary estimates include only one U.S. study, but are generally consistent with other U.S. studies.
Evidence supporting this recommendation is of classes: A, B, C, R