• Institute for Clinical Systems Improvement (ICSI). Preventive services for children and adolescents. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007 Oct. 80 p. [152 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Preventable diseases or conditions such as:

• Infectious diseases such as diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, meningitis, hepatitis B, varicella, influenza, pneumococcal pneumonia, hepatitis A, rotavirus infection
• Vision loss
• Chlamydia infection
• Cervical cancer
• Sudden infant death syndrome (SIDS)
• Injuries due to motor vehicles
• Disorders resulting from inborn errors of metabolism
• Obesity
• Tobacco use

The guideline developers also discuss, but make no specific recommendations for, preventive services related to the following conditions:

• Elevated blood lead levels
• Breast cancer
• Dental and periodontal disease
• Developmental and behavioral disorders
• Domestic violence and abuse
• Dyslipidemia
• Dysplasia of the hip
• Hearing loss
• Injuries due to bicycles, burns, choking, falls, firearms, poisoning, and water
• Iron deficiency
• Pregnancy
• Scoliosis
• Second-hand smoke exposure
• Sexually transmitted infection (STI) (other than chlamydia)
• Skin cancer
• Alcohol and other substance use/abuse
• Undescended testicles
• Viral upper respiratory infection
• Child maltreatment
• Anemia
• Tuberculosis

Counseling
Evaluation
Prevention
Risk Assessment
Screening

Family Practice
Internal Medicine
Obstetrics and Gynecology
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Physician Assistants
Physicians

• To provide a comprehensive approach to the provision of preventive services, counseling, education, and disease screening for average-risk, asymptomatic individuals from birth through age 18
• To increase regular use of health-risk assessments
• To increase the percentage of patients who are on time with recommended immunizations
• To reduce missed opportunities for administering immunizations
• To decrease the percent of patients who are behind with recommended immunizations by creating a catch-up plan
• To increase the percent of sexually active female patients under the age of 25 who are screened for chlamydia
• To increase percentage of children age four years and younger who have had vision screening

Average-risk, asymptomatic individuals from birth through age 18

There are occasional exceptions to this for high-risk populations where noted.

Risk Assessment/Prevention

1. Risk stratification and health assessment
2. Using nearly every patient contact to identify and address preventive service needs
3. Immunizations, including:
   • Diphtheria, tetanus, acellular pertussis (DTaP) vaccine
   • Tetanus-diphtheria (Tdap) booster
   • Inactivated poliovirus (IPV) vaccine
   • Measles, mumps, rubella (MMR) or combined measles, mumps, rubella and varicella (MMRV) vaccine
   • Pneumococcal vaccine (PCV7)
   • Varicella vaccine
   • Haemophilus influenzae type b (Hib) vaccine
   • Rotavirus vaccine
   • Hepatitis B vaccine
   • Influenza vaccine
   • Hepatitis A vaccine
   • Meningococcal vaccine
   • Human papilloma virus (HPV) vaccine

Screening

Screening maneuvers, including:

• Chlamydia screening
• Vision screening
• Cervical cancer screening
• Neonatal metabolic screening
• Obesity screening
• Tobacco use screening and intervention in adolescents

Counseling

Counseling and education on the following topics:

• Injury prevention: motor vehicle
• Sudden infant death syndrome (SIDS)

Additionally, the following preventive services are discussed, but do not have sufficient evidence of effectiveness to warrant a recommendation:

• Blood lead testing
• Clinical breast exams
• Counseling about dental and periodontal disease
• Assessment of developmental and behavioral disorders
• Domestic violence and abuse screening and counseling
• Screening for dyslipidemia
• Hip dysplasia screening
• Hearing screening
• Injury prevention screening: bicycle, poisoning, burns, choking, falls, firearms, water
• Iron deficiency screening
• Nutritional counseling
• Preconception counseling
• Pregnancy prevention counseling
• Scoliosis screening
• Secondhand smoke exposure counseling
• Sexually transmitted infection (STI) (other than chlamydia) counseling and screening
• Skin cancer prevention counseling
• Alcohol use screening and counseling
• Undescended testicle screening
• Viral upper respiratory infection prevention counseling

The following preventive services are discussed, but not supported by evidence:

• Blood chemistry panels
• Child maltreatment screening
• Hemoglobin (for anemia screening)
• Tuberculin skin test (routine)
• Urinalysis

• Effectiveness of preventive screening
• Effectiveness of preventive counseling and education
• Effectiveness of immunizations
• Predictive value of screening tests

Searches of Electronic Databases

A literature search of clinical trials, meta-analysis, and systematic reviews is performed.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Key conclusions (as determined by the work group) are supported by a conclusion grading worksheet that summarizes the important studies pertaining to the conclusion. Individual studies are classed according to the system presented below, and are designated as positive, negative, or neutral to reflect the study quality.

Conclusion Grades:

Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.

Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.

Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results of different studies or because of serious doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.

Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.

Study Quality Designations:

The quality of the primary research reports and systematic reviews are designated in the following ways on the conclusion grading worksheets:

Positive: indicates that the report or review has clearly addressed issues of inclusion/exclusion, bias, generalizability, and data collection and analysis.

Negative: indicates that these issues (inclusion/exclusion, bias, generalizability, and data collection and analysis) have not been adequately addressed.

Neutral: indicates that the report or review is neither exceptionally strong nor exceptionally weak.

Not Applicable: indicates that the report is not a primary reference or a systematic review and therefore the quality has not been assessed.

Classes of Research Reports:

1. Primary Reports of New Data Collection:

   Class A:

   • Randomized, controlled trial

   Class B:

   • Cohort study

   Class C:

   • Non-randomized trial with concurrent or historical controls
   • Case-control study
   • Study of sensitivity and specificity of a diagnostic test
   • Population-based descriptive study

   Class D:

   • Cross-sectional study
   • Case series
   • Case report

2. Reports that Synthesize or Reflect upon Collections of Primary Reports:

   Class M:

   • Meta-analysis
   • Systematic review
   • Decision analysis
   • Cost-effectiveness analysis

   Class R:

   • Consensus statement
   • Consensus report
   • Narrative review

   Class X:

   • Medical opinion

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

Each guideline, order set, and protocol is developed by a 6- to 12-member work group that includes physicians, nurses, pharmacists, other healthcare professionals relevant to the topic, along with an Institute for Clinical Systems Improvement (ICSI) staff facilitator. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, one or two members may be recruited from medical groups or hospitals outside of ICSI.

The work group meets for seven to eight three-hour meetings to develop the guideline. A literature search and review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the algorithm and write the annotations and footnotes and literature citations.

Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review.

Not applicable

The guideline developers reviewed published cost analyses.

Internal Peer Review

Critical Review Process

Every newly developed guideline or a guideline with significant change is sent to Institute for Clinical Systems Improvement (ICSI) members for Critical Review. The purpose of critical review is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes necessary across systems in their organization to implement the guideline.

All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a criterion for continued membership within ICSI.

After the critical review period, the guideline work group reconvenes to review the comments and make changes, as appropriate. The work group prepares a written response to all comments.

Approval

Each guideline, order set, and protocol is approved by the appropriate steering committee. There is one steering committee each for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The steering committees review and approve each guideline based on the following:

• Member comments have been addressed reasonably.
• There is consensus among all ICSI member organizations on the content of the document.
• To the extent of the knowledge of the reviewer, the scientific recommendations within the document are current.
• Either a critical review has been carried out, or to the extent of the knowledge of the reviewer, the changes proposed are sufficiently familiar and sufficiently agreed upon by the users that a new round of critical review is not needed.

Once the guideline, order set, or protocol has been approved, it is posted on the ICSI Web site and released to members for use. Guidelines, order sets, and protocols are reviewed regularly and revised, if warranted.

Revision Process of Existing Guidelines

ICSI scientific documents are revised every 12 to 36 months as indicated by changes in clinical practice and literature. Every 6 months, ICSI checks with the work group to determine if there have been changes in the literature significant enough to cause the document to be revised earlier than scheduled.

Prior to the work group convening to revise the document, ICSI members are asked to review the document and submit comments. During revision, a literature search of clinical trials, meta-analysis, and systematic reviews is performed and reviewed by the work group. The work group meets for 1-2 three-hour meetings to review the literature, respond to member organization comments, and revise the document as appropriate.

If there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations, it is sent to members to review prior to going to the appropriate steering committee for approval.

Review and Comment Process

ICSI members are asked to review and submit comments for every guideline, order set, and protocol prior to the work group convening to revise the document.

The purpose of the Review and Comment process is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the order set and protocol. Review and Comment also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes needed across systems in their organization to implement the guideline.

All member organizations are encouraged to provide feedback on order sets and protocol, however responding to Review and Comment is not a criterion for continued membership within ICSI.

After the Review and Comment period, the work group reconvenes to review the comments and make changes as appropriate. The work group prepares a written response to all comments.

The type of supporting evidence is classified for selected recommendations (see "Major Recommendations").

In addition, key conclusions contained in the Work Group's algorithm are supported by a grading worksheet that summarizes the important studies pertaining to the conclusion. The type and quality of the evidence supporting these key recommendations is graded for each study.

This guideline is a synthesis of recommendations from other Institute for Clinical Systems Improvement (ICSI) guidelines, primary evidence through literature reviews, other professional groups, particularly United States Preventive Services Task Force (USPSTF), and workgroup consensus.

Improved use of a comprehensive approach to the provision of preventive services, counseling, education, and disease screening for average-risk, asymptomatic children and adolescents as demonstrated by:

• Increased regular assessment of health risks
• Increased percentage of patients who are up-to-date on immunizations
• Reduction in missed opportunities for administering immunization
• Decreased percentage of patients who are behind with recommended immunizations
• Increased percentage of female patients being screened for cervical cancer
• Increased percentage of sexually active female patients under the age of 25 who are screened for chlamydia
• Increased percentage of children age four and younger who have had vision screening

Not stated

• This clinical guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition. A guideline will rarely establish the only approach to a problem.
• This clinical guideline should not be construed as medical advice or medical opinion related to any specific facts or circumstances. Patients are urged to consult a health care professional regarding their own situation and any specific medical questions they may have.
• This resource is intended to assist in the prioritization of screening maneuvers, testing, and counseling opportunities. It is not intended to diagnose or treat any condition. Consequently, once a health issue or condition has been uncovered, other guidelines will take precedence during any further diagnosis and management.
• It is the guideline development group's assumption that this guideline will primarily serve as a guide for medical groups to develop practice systems for their delivery. While individual clinicians are welcome to refer to this guide, the group does not expect that to be common and it certainly is not the best way to provide important services at high rates. Such an achievement clearly requires the establishment of systems that rely on standing orders, task delegation, reminders, and other automatic ways to identify needs and provide the services.
• While there is good evidence that modifying certain behaviors has positive health benefits (unsafe sex, accidents and safety, nutrition, physical activity), there is minimal evidence at present that screening for these conditions or asking about them in the context of a risk assessment, even if followed by advice from a physician or other provider, will result in a change in behavior or positive outcomes. Therefore, this guideline includes:
  • Minimal recommendations for risk assessment to drive counseling for what are largely lifestyle issues
  • Specific recommendation that risk assessment and counseling about lifestyle not be considered suitable parameters for systematic implementation measures
  • Counseling messages for those clinicians who want to provide such counseling or whose patients express an interest in receiving this information
• The Preventive Services work group has begun a more thorough analysis of the evidence surrounding the use of the physical exam during the provision of preventive services for children. In many areas, there is insufficient evidence surrounding individual components of the physical exam. There are expert recommendations supporting individual components, but study of these elements has been limited by several factors, including the technical difficulty of consistent performance of some exam components, the relative low frequency of the diseases that screening is searching for and lacking, inconclusive or inadequate evidence of the effectiveness of intervention. The work group has begun to break out individual components of the exam into a separate section of this document. The group plans to expand that section in future revisions to more completely visit all of the components of physical examination. The group recognizes that changing these elements will be difficult for some providers and some patients. Therefore, the work group leaves the inclusion of specific components to the desires of individual medical groups. The Preventive Service work group encourages medical groups to focus on the provision of services that clearly have strongest evidence supporting their delivery.
• There is insufficient evidence to recommend one prevention visit schedule over another in terms of lowering mortality and morbidity, recognizing disability, promoting optimal growth and development, or helping patients achieve longer, more productive lives. Many services can be provided during routine visits. Similarly, an assessment of preventive services needs can be incorporated into any visit. The visit schedules recommended in these guidelines may augment a clinic's ability to assure provision of preventive services, but this may be unnecessary over time as effective clinic systems allow the services to be incorporated into other clinic visits.
• Evidence is insufficient to warrant ranking of recommendations for a number of preventive services. Refer to the "Major Recommendations" field and the original guideline document for more information.

Once a guideline is approved for general implementation, a medical group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they may form an action group.

In the action group, each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experiences and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative.

Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation.

Detailed measurement strategies are presented to help close the gap between clinical practice and the guideline recommendations. Summaries of the measures are provided in the National Quality Measures Clearinghouse (NQMC).

Key Implementation Recommendations

The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline.

1. Develop a process that allows parents/guardians to complete a risk assessment questionnaire prior to periodic well-child visits and update as necessary. This questionnaire then becomes part of the medical record.
2. The results of the health risk assessment questionnaire are used to identify needs for counseling and other preventive services.
3. The provision of needed preventive services are documented in the medical record and monitored.
4. Develop a process that identifies patients (routine office visits) behind in their preventive visit schedule and create a catch-up plan.
5. Develop a risk-assessment questionnaire that allows for easy identification and monitoring of counseling needs.
6. Risk-assessment questionnaires should be in a consistent and easily accessible place in the patient's chart.
7. Develop electronic data systems to track the immunization status of patients under the provider's care, with the capability to produce reminders and recalls of upcoming or overdue immunizations.
8. Remove barriers to immunization services.

Staying Healthy

Effectiveness
Patient-centeredness

• Institute for Clinical Systems Improvement (ICSI). Preventive services for children and adolescents. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007 Oct. 80 p. [152 references]

Not applicable: The guideline was not adapted from another source.

1995 Jun (revised 2007 Oct)

Institute for Clinical Systems Improvement - Private Nonprofit Organization

The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.

Preventive Services Steering Committee

Work Group Members: Lawrence Morrissey, MD (Work Group Leader) (Stillwater Medical Group) (Pediatrics); Jacquelyn Bartz, MS, RD, CD (Mayo Clinic) (Dietitian); Karla Grenz, MD (Allina Medical Clinic) (Family Practice); Roy Mortinsen, MD (Sanford Health) (Family Practice); Don Pine, MD (Park Nicollet Health Services) (Family Practice); Leif Solberg, MD (HealthPartners Medical Group) (Family Practice); John M. Wilkinson, MD (Mayo Clinic) (Family Practice); Lisa Harvey, RD, MPH (Park Nicollet Health Services) (Health Education); Peter Rothe, MD (HealthPartners Medical Group) (Internal Medicine); Judy Branstad, RN (Fairview Health Services) (Nursing); Sheila Goodman, MD (Obstetrics and Gynecology Associates, PA) (OB/GYN); Amy Hentges, MD (Allina Medical Clinic) (Pediatrics); Sharnell Valentine, MD, FAAP (St. Mary's/Duluth Clinic Health System) (Pediatrics); Michael Maciosek, PhD (HealthPartners Medical Group) (Resarch); Penny Fredrickson (Institute for Clinical Systems Improvement) (Measurement and Implementation Advisor); Melissa Marshall, MBA (Institute for Clinical Systems Improvement) (Facilitator); Pam Pietruszewski, MA (Institute for Clinical Systems Improvement) (Facilitator)

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

None available

This summary was completed by ECRI on July 10, 2000. The information was verified by the guideline developer on April 25, 2001. This summary was updated by ECRI on April 15, 2002 and most recently on March 14, 2003. The updated information was verified by the guideline developer on May 15, 2003. This summary was updated again by ECRI on March 22, 2004, November 10, 2004, December 7, 2004, December 29, 2005, and on January 25, 2007. This summary was updated by ECRI Institute on July 9, 2007 following the FDA advisory on RotaTeq (Rotavirus, Live, Oral, Pentavalent) vaccine. This NGC summary was updated by ECRI Institute on December 21, 2007.

This NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines.