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Guide to Clinical Preventive Services, 2008

Appendixes

Appendix A: How the U.S. Preventive Services Task Force Grades Its Recommendations

The U.S. Preventive Services Task Force (USPSTF) assigns one of five letter grades to each of its recommendations (A, B, C, D, or I). The USPSTF changed its grade definitions based on a change in methods in May 2007.

Grade Definitions After May 2007

What the Grades Mean and Suggestions for Practice

The USPSTF updated its definitions of the grades it assigns to recommendations and now includes“suggestions for practice” associated with each grade. The USPSTF has also defined levels of certainty regarding net benefit. These definitions apply to USPSTF recommendations voted on after May 2007.

Grade Definition Suggestions for Practice
A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.
C The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.
D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.
I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Levels of Certainty Regarding Net Benefit

Level of Certainty* Description
High The available evidence usually includes consistent results from well-designed, wellconducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate

The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as:

  • The number, size, or quality of individual studies.
  • Inconsistency of findings across individual studies.
  • Limited generalizability of findings to routine primary care practice.
  • Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low

The available evidence is insufficient to assess effects on health outcomes. Evidence
is insufficient because of:

  • The limited number or size of studies.
  • Important flaws in study design or methods.
  • Inconsistency of findings across individual studies.
  • Gaps in the chain of evidence.
  • Findings not generalizable to routine primary care practice.
  • Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.

* The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

Grade Definitions Prior to May 2007

The definitions below (of USPSTF grades and quality of evidence ratings) were in use prior to the update in methods and apply to recommendations voted on by the USPSTF prior to May 2007.

A Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

C No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

D Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

I Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Quality of Evidence

The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

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Appendix B: Members of the U.S. Preventive Services Task Force 2001-2007

Janet D. Allan, Ph.D., R.N., C.S., F.A.A.N., School of Nursing, University of Maryland, Baltimore County; Baltimore, MD
Alfred O. Berg, M.D., M.P.H., Department of Family Medicine, University of Washington; Seattle, WA
Ned Calonge, M.D., M.P.H., Colorado Department of Public Health and Environment; Denver, CO
Thomas G. DeWitt, M.D., Department of Pediatrics, Children's Hospital Medical Center, Cincinnati, OH
Allen J. Dietrich, M.D., Dartmouth Medical School, Hanover, NH
Paul S. Frame, M.D., Tri-County Family Medicine; Cohocton, NY
Joxel Garcia, M.D., M.B.A., Pan American Health Organization; Washington, DC
Leon Gordis, M.D., Dr. P.H., Epidemiology Department, Johns Hopkins Bloomberg School of Public Health; Baltimore, MD
Kimberly D. Gregory, M.D., M.P.H., Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center; Los Angeles, CA
David Grossman, M.D., M.P.H., Center for Health Studies, Group Health Cooperative, University of Washington, Seattle, WA
Russell Harris, M.D., M.P.H., University of North Carolina School of Medicine; Chapel Hill, NC
Charles J. Homer, M.D., M.P.H., National Initiative for Children's Healthcare Quality; Boston, MA
George Isham, M.D., M.S., HealthPartners Minneapolis, MN
Mark S. Johnson, M.D., M.P.H., Department of Family Medicine, New Jersey Medical School; University of Medicine and Dentistry of New Jersey; Newark, NJ
Kenneth Kizer, M.D., M.P.H., National Quality Forum, Washington, DC
Jonathan D. Klein, M.D., M.P.H., Department of Pediatrics, University of Rochester; Rochester, NY
Tracy A. Lieu, M.D., M.P.H., Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School; Boston, MA
Michael L. LeFevre, M.D., M.S.P.H., University of Missouri, School of Medicine, Columbia, MO
Rosanne Leipzig, M.D., Ph.D., Geriatrics and Adult Development Medicine, Health Policy, Mount Sinai School of Medicine New York, NY
Carol Loveland-Cherry, Ph.D., R.N., Office of Academic Affairs, University of Michigan School of Nursing; Ann Arbor, MI
Lucy N. Marion, Ph.D., R.N., School of Nursing, Medical College of Georgia, Augusta, GA
Bernadette Melnyk, Ph.D., R.N., C.P. N.P./N.P.P., College of Nursing & Healthcare Innovation, Arizona State University, Phoenix, AZ
Virginia A. Moyer, M.D., M.P.H., Department of Pediatrics, University of Texas Health Science Center; Houston, TX
Cynthia D. Mulrow, M.D., M.Sc., University of Texas Health Science Center; Audie L. Murphy Memorial Veterans Hospital; San Antonio, TX
Judith K. Ockene, Ph.D., M.Ed., Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School; Worcester, MA
C. Tracy Orleans, Ph.D., Department of Research and Evaluation, The Robert Wood Johnson Foundation; Princeton, NJ
Jeffrey F. Peipert, M.D., M.P.H., Women and Infants' Hospital; Providence, RI
Nola J. Pender, Ph.D., R.N., School of Nursing, University of Michigan; Ann Arbor, MI
Diana B. Petitti, M.D., M.P.H., University of Southern California; Pasadena, CA
George F. Sawaya, M.D., Department of Obstetrics, Gynecology, and Reproductive Sciences; Department of Epidemiology and Biostatistics; University of California, San Francisco, San Francisco, CA
J. Sanford (Sandy) Schwartz, M.D., University of Pennsylvania School of Medicine and Wharton School, Philadelphia, PA
Harold C. Sox, Jr., M.D., Department of Medicine, Dartmouth-Hitchcock Medical Center; Lebanon, NH
Albert L. Siu, M.D., M.S.P.H., Brookdale Department of Geriatrics and Adult Development, Mount Sinai Medical Center; New York, NY
Steven M. Teutsch, M.D., M.P.H., Merck and Company, Inc. West Point, PA
Carolyn Westhoff, M.D., M.Sc., Department of Obstetrics and Gynecology, Columbia University; New York, NY
Timothy Wilt, M.D., M.P.H., Department of Medicine, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN
Steven H. Woolf, M.D., M.P.H., Department of Family Practice, Preventive Medicine, and Community Health, Virginia Commonwealth University; Fairfax, VA
Barbara P. Yawn, M.D., M.S.P.H., M.Sc., Olmstead Research Center; Rochester, MN

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Appendix C: Acknowledgments

AHRQ Staff Supporting the USPSTF 2001-2008

David Atkins, M.D., M.P.H.; Mary Barton, M.D., M.P.P.; Dana Best, M.D., M.P.H.; Joel Boches; Helen Burstin, M.D., M.P.H.; Mackenzie Cross; Sandra K. Cummings; Elizabeth Edgerton, M.D., M.P.H.; Farah Englert; Kenneth Fink, M.D., M.G.A., M.P.H.; Janice L. Genevro, Ph.D., M.S.W.; Barbara Gordon; Margi Grady; Janelle Guirguis-Blake, M.D.; Patrik Johansson, M.D.; Heather Johnson; Douglas Kamerow, M.D., M.P.H.; Hazel Keimowitz, M.A.; Claire Kendrick, M.S.Ed.; Kristie Kiser; David Lanier, M.D.; Morgan Liscinsky; Kenneth Lin, M.D.; Iris Mabry, M.D., M.P.H.; Corey Mackson, M.S.A.; David Meyers, M.D.; Tess Miller, Dr.P.H.; Kevin Murray; Barbara Najar, M.P.H.; Bridget O'Connell; Nilam Patel, M.P.H.; Amy Pfeiffer; Gurvaneet Randhawa, M.D., M.P.H.; Stacia Sanvick; Eve Shapiro; Randie Siegel, M.S.; Jean Slutsky, P.A., M.S.P.H.; Bill Sowers; Marion Torchia; Tricia Trinité, M.S.P.H., A.P.R.N.; Gloria Washington; Tracy Wolff, M.D., M.P.H.

Evidence-Based Practice Centers Supporting the USPSTF 2001-2008

The following researchers working through three AHRQ Evidence-Based Practice Centers prepared systematic evidence reviews and evidence summaries as resources on topics under consideration by the USPSTF.

Oregon Evidence-Based Practice Center

Mikel Aickin, Ph.D.; Sarah Baird, M.S.; Vance Bauer, M.A.; Tracy Beil, M.S.; Christina Bougatsos, B.S.; Jessica Burnett; David Buckley, M.D.; Taryn Cardenas, B.S.; Susan Carson, M.P.H.; Benjamin K.S. Chan, M.S.; Roger Chou, M.D.; Elizabeth Clark, M.D., M.P.H; Tracy Dana, M.L.S.; Robert Davis, M.D., M.P.H.; Stephanie Detlefsen, M.D.; Karen B. Eden, Ph.D.; Michelle Eder, Ph.D.; Craig Fleming, M.D.; Michele Freeman, M.P.H.; Rochele Fu, Ph.D.; Betsy Garlitz, M.D.; Nancy Glass, Ph.D., M.P.H., R.N.; Rachel Gold, Ph.D., M.P.H; Carla A. Green, Ph.D., M.P.H.; Jeanne- Marie Guise, M.D., M.P.H.; Andrew Hamilton, M.S., M.L.S.; Elizabeth Haney, M.D; Emily Harris, Ph.D., M.P.H.; Mark Helfand, M.D., M.P.H.; Theresa Hillier, M.D., M.S.; Laurie Huffman, M.S.; Linda Humphrey, M.D., M.P.H.; Devan Kansagara, M.D.; P. Todd Korthuis, M.D., M.P.H; Kathryn Pyle Krages, M.A.; Erin Leblanc, M.D., M.P.H.; Beth Liles, M.D.; Jennifer Lin, M.D.; Susan Mahon, M.P.H.; Yasmin McInerney, M.D.; Heather McPhillips, M.D., M.P.H.; Yvonne Michael, Sc.D.; Jill Miller, M.D.; Cynthia D. Morris, Ph.D., M.P.H.; Arpana Naik, M.D.; Heidi D. Nelson, M.D., M.P.H.; Rebecca Newton-Thompson, M.D., M.Sc.; Susan Norris, M.D., M.P.H.; Peggy Nygren, M.S.; Michelle Pappas, B.A.; Rita Panosca, M.D.; Kathy Pedula, M.S.; Daphne Plaut, M.L.S.; Michael R. Polen, Ph.D.; Elizabeth O’Connor, Ph.D.; Gary Rischitelli, M.D., J.D., M.P.H.; Cheryl Ritenbaugh, Ph.D., M.P.H.; Kevin Rogers, M.D.; Somnath Saha, M.D., M.P.H.; Scott A. Shipman, M.D., M.P.H.; Paula R. Smith, R.N., B.S.N.; Ariel K. Smits, M.D., M.P.H.; Robert Steiner M.D.; Kelly Streit, M.S., R.D.; Lina M.A. Takano, M.D., M.S.; Diane Thompson, M.S.; Kari Tyne, M.D.; Kimberly Vesco, M.D., M.P.H.; Kim Villemyer, B.A.; Miranda Walker, B.A.; Carolyn Westhoff, M.D., M.Sc.; Evelyn P. Whitlock, M.D., M.P.H.; Selvi B.Williams, M.D., M.P.H.; Jennifer Wisdom, Ph.D., M.P.H.; Sarah Zuber, M.S.W.

RTI International/University of North Carolina Evidence-Based Practice Center

Alice Ammerman, Dr.P.H., R.D.; James D. Bader, D.D.S., M.P.H.; Rainer Beck, M.D.; John F. Boggess, M.D.; Malaz Boustani, M.D., M.P.H.; Seth Brody, M.D.; Audrina J. Bunton; Katrina Donahue, M.D., M.P.H.; Louise Fernandez, PA-C, R.D., M.P.H.; Kenneth Fink, M.D., M.G.A., M.P.H.; Carol Ford, M.D.; Angela Fowler-Brown, M.D.; Bradley N. Gaynes, M.D., M.P.H.; Paul Godley, M.D., M.P.H.; Susan A. Hall, M.S.; Laura Hanson, M.D., M.P.H.; Russell Harris, M.D., M.P.H.; Katherine E.Hartmann, M.D., Ph.D.; Michael Hayden, M.D.; M. Brian Hemphill, M.D.; Alissa Driscoll Jacobs, M.S., R.D.; Jana Johnson; Linda Kinsinger, M.D., M.P.H.; Carol Krasnov; Ramesh Krishnaraj; Carole M. Lannon, M.D., M.P.H.; Carmen Lewis, M.D., M.P.H.; Kathleen N. Lohr, Ph.D.; Linda J. Lux, M.P.A.; Kathleen McTigue, M.D., M.P.H.; Catherine Mills, M.A.; Kavita Nanda, M.D., M.H.S.; Carla Nester, M.D.; Britt Peterson, M.D., M.P.H.; Christopher J. Phillips, M.D., M.P.H.; Michael Pignone, M.D., M.P.H.; Mark Pletcher, M.D., M.P.H.; Saif S. Rathore; Melissa Rich, M.D.; Gary Rozier, D.D.S.; Jerry L. Rushton, M.D., M.P.H.; Lucy A. Savitz; Joe Scattoloni; Stacey Sheridan, M.D., M.P.H.; Sonya Sutton, B.S.P.H.; Jeffrey A. Tice, M.D.; Suzanne L. West, Ph.D.; B. Lynn Whitener, Dr.P.H., M.S.L.S.; Margaret Wooddell, M.A.; Dennis Zolnoun, M.D.

University of Ottawa Evidence-Based Practice Center

Nicholas Barrowman, Ph.D.; Catherine Code, M.D., F.R.C.P.C.; Catherine Dubé, M.D., M.Sc., F.R.C.P.C.; Gabriela Lewin, M.D.; David Moher, Ph.D.; Alaa Rostom, M.D., M.Sc., F.R.C.P.C.; Margaret Sampson, M.I.L.S.; Alexander Tsertsvadze, M.D., M.Sc.

Liaisons to the USPSTF

Professional Organizations

American Academy of Family Physicians
American Academy of Nurse Practitioners
American Academy of Pediatrics
American Academy of Physician Assistants
American College of Obstetricians and Gynecologists
American College of Physicians
American College of Preventive Medicine
American Medical Association
American Osteopathic Association
America’s Health Insurance Plans
National Committee for Quality Assurance
National Organization of Nurse Practitioner Faculties

Government Agencies

Canadian Task Force on Preventive Health Care
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Health Resources and Services Administration
Indian Health Services
Military Health System
National Institutes of Health
Office of Disease Prevention and Health Promotion
U.S. Food and Drug Administration
VA National Center for Health Promotion and Disease Prevention

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Appendix D: Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedules

  • Recommended Immunization Schedule for Persons Aged 0-6 Years (PDF File [244 KB], PDF Help).
  • Recommended Immunization Schedule for Persons Aged 7-18 Years (PDF File [110 KB], PDF Help).
  • Catch-up Immunization Schedule for Persons Aged 4 Months-18 Years Who Start Late or Are More Than 1 Month Behind (PDF File [258 KB], PDF Help.
  • Recommended Adult Immunization Schedule
    • Figure 1. Recommended adult immunization schedule, by vaccine and age group (PDF File [536 KB], PDF Help.
    • Figure 2. Vaccines that might be indicated for adults based on medical and other indications (PDF File [195 KB], PDF Help.

Persons with disabilities experiencing problems accessing portions of these PDF files should contact Margi Grady at (301) 427-1589. The accessible version of these tables will be available by October 1, 2008.

The USPSTF recognizes the importance of immunizations in primary disease prevention. The Task Force refers to recommendations made by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) for immunization of children and adults. The methods used by ACIP to review evidence on immunizations may differ from the methods used by the USPSTF.

More Resources on Preventive Services

Prevention Dissemination and Implementation (Put Prevention Into Practice) aims to improve delivery of appropriate clinical preventive services. The program disseminates the USPSTF recommendations in multiple formats and facilitates health care delivery systems' implementation of evidence-based preventive services through partnerships, communication, user-driven tools, and outreach. For more information, go to www.ahrq.gov/clinic/ppipix.htm

The Guide to Community Preventive Services provides recommendations on population-based interventions to promote health and prevent disease, injury, disability, and premature death. Recommendations are promulgated by the Task Force on Community Preventive Services, an independent group appointed by the Director of the Centers for Disease Control and Prevention. For information, go to http://www.thecommunityguide.org.

The National Guideline Clearinghouse™ (NGC) is a database of evidence-based clinical practice guidelines and related documents. To access, go to http://www.guideline.gov.

The Adult Preventive Care Timeline, based on USPSTF recommendations, is an at-a-glance wall poster, showing which preventive services your patients need, and when. To order, call the AHRQ Publications Clearinghouse at 1-800-358-9295 or send an e-mail to ahrqpubs@ahrq.hhs.gov.

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AHRQ Publication No. 08-05122
Current as of September 2008

Internet Citation:

The Guide to Clinical Preventive Services 2008—Recommendations of the U.S. Preventive Services Task Force. Pocket Guide. Agency for Healthcare Research and Quality, Rockville, MD. AHRQ Publication No. 08-05122, September 2008. http://www.ahrq.gov/clinic/pocketgd08/

 
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