Section 2: Topic Selection and Overview of Updating Process

2.1 New USPSTF Topic Nominations

The U.S. Preventive Services Task Force (USPSTF) solicits new topics for consideration through a periodic notice in the Federal Register (Appendix V) and solicitation of professional liaison organizations, including but not necessarily limited to the partner organizations. Task Force members may also generate new topics for consideration. The USPSTF first considers whether newly nominated topics are within the scope of the USPSTF (that is, whether they relate to a primary or secondary preventive service that is relevant to primary care, and whether they address a disease with a substantial health burden). It then prioritizes the topics by using specific criteria:

1. Public health importance (burden of suffering, and expected effectiveness of preventive services to reduce that burden).
2. Potential for a Task Force recommendation to affect clinical practice (based on existing controversy or the belief that a gap exists between evidence and practice).

2.2 Topic Prioritization of New and Updated Topics

Periodically throughout the year, the Task Force Topic Prioritization Work Group (TP WG) drafts a prioritized list of topics, including new topics and updates, to be worked on during that year. This list will be made according to the two criteria above, with an additional criterion:

3. New evidence (e.g., new studies or new analysis of previous data) that has the potential to change prior recommendations.

The criteria are combined in an assessment of the topic as a whole, rather than being used as a scoring system. The ultimate goal is to balance the annual portfolio by populations, types of services (screening, counseling, preventive medications), disease types (e.g., cancer, endocrine disease) and size of project (update versus new topic). The Task Force also aims to update topics every 5 years, in order to keep recommendations in the Task Force library current according to criteria established by the National Guidelines Clearinghouse™, an Agency for Healthcare Research and Quality (AHRQ)-initiated public resource for evidence-based guidelines.

2.3 Types of Topics in Task Force Library

The current USPSTF library consists of active and inactive topics. Active and inactive recommendations are identified as such on the Task Force Web site (http://www.preventiveservices.ahrq.gov ).

2.3.1 Active topics

Active topics include (1) new topics, (2) updated topics, (3) reaffirmed topics and (4) topics for which the Task Force has elected to defer to the recommendations of other evidence-based groups. The procedures for developing recommendations for these topics are described below. (Go to Table 1 for an overview of the types of topics the USPSTF considers.)

2.3.1.1 New Topics

The processes for developing work plans, assessing evidence, and making recommendations for these topics are given in detail in Sections 3, 4, and 5.

2.3.1.2 Updated topics

The processes for developing work plans, assessing evidence, and making recommendations for these topics are given in detail in Sections 3 and 4.

2.3.1.3 Reaffirmed Topics

A reaffirmation update is performed for selected topics that the Task Force decides to keep current because the topic is within the Task Force's scope and a Task Force priority, and because there is a compelling reason for the Task Force to make a recommendation. Topics that belong in this category are well-established evidence-based standards of practice in current primary care medical practice (e.g., screening for hypertension). While the Task Force would like these recommendations to remain active and current as a part of its library of preventive services, it has determined that only a very high level of evidence would change the recommendation. Such a recommendation would have been given an A, B, or D grade.

The goal of this process is to reconsider a recommendation that is supported by a high level of evidence. Therefore, the goal of the search for evidence is to find new and substantial evidence that would be sufficient to change the recommendation (for example, from an A recommendation to a D recommendation, or vice versa). The process is as follows:

1. The Topic Prioritization Work Group (TP WG) identifies a topic for a reaffirmation update and presents this categorization to the entire Task Force for approval at a meeting.
2. AHRQ Staff reviews the previous recommendation statement and evidence report.
3. AHRQ staff consults experts in the specific field to identify important evidence published since the last evidence review.
4. AHRQ staff identifies recommendations from other federal agencies and professional organizations.
5. AHRQ staff consults with Task Force leads to develop the Analytic Framework, Key Questions, and inclusion and exclusion criteria (i.e., criteria for admissible evidence) for the topic.
6. AHRQ staff performs literature searches in the PubMed and Cochrane data bases on benefits and harms of the preventive service. The literature search uses appropriate MeSH (medical subject heading) terms, searching for studies published since the last review (3 months prior to the end date of the previous search), limited to the English language, to humans, and to the journals in the abridged Index Medicus (120 "core clinical journals" in PubMed®). In general, for the literature search on benefits, the search is limited to meta-analyses, systematic reviews, and randomized, controlled trials (RCTs). For harms, the search generally includes only meta-analyses, systematic reviews, RCTs, cohorts, case-control studies, and case series of large, multi-site databases. AHRQ staff also checks reference lists of systematic reviews for RCTs and other high-quality studies. The review is discussed with the Task Force lead, with a member of the TP WG, and with the full TP WG. The TP WG makes a decision whether the evidence indicates that the topic is ready to be reaffirmed or whether the topic needs to be re-structured as a targeted update.
7. AHRQ staff prepares a brief summary of the results of the literature search.
8. AHRQ staff, in collaboration with Task Force leads, prepares a recommendation statement that includes the summary statement of the recommendation and evidence, updated clinical considerations, and the brief summary of the literature search. A new date is placed on the recommendation.
9. The results of the literature search, expert discussion, and draft recommendation statement is presented to the TP WG and later to the entire Task Force. After discussion, the Task Force votes on this recommendation as with any other.

2.3.1.4 Topics Referred to Other Evidence-based Groups

The recommendations for some topics in the USPSTF library are referred to another evidence-based organization that the Task Force believes is in a better position to make accurate and timely recommendations. A good example is the Advisory Committee on Immunization Practices (ACIP), a non-federal panel of immunization experts convened by the Centers for Disease Control and Prevention (CDC). The Task Force has referred recommendations on immunizations to the ACIP.

A "referred" topic is one for which the TF had previously issued a recommendation, that the TF decides to keep active (because it is a Task Force priority and the topic is within the scope of the Task Force), but for which there is another organization with evidence-based methods that is in a better position to make accurate and timely recommendations. The identified organization has the resources for timely updates of the evidence and has a scientifically sound methodology for its evidence reviews. (Select for list of criteria for other organizations.) Other than immunizations, the Task Force anticipates that few topics will fall into this category. The process for designating a topic as a "referred" topic is as follows:

1. A topic to be referred to others is one for which there is a potential organization that is making recommendations that appear to be evidence-based. The TP WG decides to consider this option for this topic.
2. The staff at AHRQ reviews the previous Task Force recommendation statement and evidence report.
3. The AHRQ staff identifies the recommendations and the methods of review from other federal agencies and professional organizations.
4. The AHRQ staff prepares a brief summary of why the topic was chosen for referral, a reference to the Web site of the chosen organization's recommendations on the topic, a statement that the organization's methodology may be different from the USPSTF, a new recommendation date, and a statement that the previous evidence review will not be updated.
5. The TP WG discusses the issue and decides whether to proceed with a full Task Force discussion.
6. If the TP WG decides to proceed, the AHRQ summary is presented at a Task Force meeting for general discussion. The Task Force then votes on the decision to defer the topic to the specific organization.
7. USPSTF Web site contents for these topics are as follows: single summary paragraph on Web site including a web link to the organization's recommendation. There would be no link to prior USPSTF recommendation statements, and no evidence reports on the topic would be made available on the web.
8. The Task Force's decision to refer is re-considered every 5 years, as with other topics.
9. Criteria for referring to another organization's recommendation:
   1. The organization is identified by the USPSTF as an appropriate source.
   2. The organization systematically reviews the evidence for the preventive service.
   3. The organization has a process for updating recommendations in a timely manner.
   4. The organization has a written and available evidence-based methodology that the Task Force judges to be adequate for the topic.

2.3.2 Inactive Topics

The Task Force has decided to inactivate some recommendations made in previous years (e.g., those for electronic fetal monitoring, home uterine monitoring, and counseling for dental disease). Inactive topics are topics that the Task Force has decided not to update because they are:

1. No longer relevant to clinical practice due to changes in technology, new understanding of disease etiology/natural history, or evolving natural history of the disease.
2. Not relevant to primary care setting, because the service is not implemented in a primary care setting or not referable by a primary care provider (PCP).
3. Low public health burden.
4. Otherwise out of USPSTF scope.

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