I. Introduction

NORC at the University of Chicago (NORC) is pleased to present this Final Report, Evaluation of the U.S. Preventive Services Task Force Recommendations for Clinical Preventive Services, to the Agency for Health Care Research and Quality (AHRQ) at the United States Department of Health and Human Services (HHS). This project applies qualitative methods to describe the implementation of the U.S. Preventive Services Task Force (USPSTF) recommendations for clinical preventive services in a closed-panel health plan, open-panel health plan, hybrid health plan having both open- and closed-panel characteristics, and governmental health plan. The four health plan site selections serve to address AHRQ's interest in the adoption and integration of the USPSTF recommendations at the systems-level. This report represents a synthesis of qualitative interviews, prevention materials provided by sites, and other published literature. Overall, we report on findings from over 40 discussions with respondents from four different health plans. Our findings address the adoption, integration, delivery, and dissemination of the USPSTF recommendations in different types of health plans. We also highlight the barriers to integration and delivery of the recommendations and offer suggestions for improving the dissemination of the recommendations.

Importance of the Current Study

In 1984, the U.S. Public Health Service created the USPSTF as an independent panel of experts in primary care and prevention that systematically review the evidence of effectiveness and develop recommendations for clinical preventive services. The Agency for Healthcare Research and Quality (AHRQ) began sponsoring USPSTF activities in 1998 and includes the USPSTF recommendations as part of their diverse Prevention Portfolio. The USPSTF recommendations are developed by a team of clinicians and are based on a thorough review of evidence (including individual studies such as randomized controlled trials), costs, and potential benefits and harms. Recommendations are issued specific to conditions of public health significance that can be addressed through preventive strategies. Recommendations are categorized on a scale from "A" (strongly recommended) to "D" (not recommended), with an additional "I" category for prevention activities where evidence is insufficient. This allows clinicians to quickly assess the evidence behind a prevention strategy without needing to conduct extensive research. A great deal of research goes into the compilation of the USPSTF recommendations.

Despite the importance of the USPSTF recommendations and the widespread availability of the USPSTF recommendations, case studies, physician and patient surveys, chart reviews, and observational studies provide evidence that patients are not consistently receiving recommended preventive services.^1-7 Several barriers hinder the implementation of the USPSTF recommendations such as a lack of physician time, patient attitudes and expectations, lack of implementation tools, physician attitudes, and financial disincentives.⁸

Although there is existing research on the implementation and use of USPSTF recommendations at the individual clinician and group practice levels, there has been little research at the health plan level. On behalf of AHRQ, NORC had previously conducted an assessment of the use of USPSTF recommendations among community-based health care practices and found that physicians consider the recommendations valuable, but sometimes inconsistent with their local standard of care. This finding highlights the need for examining the use of the USPSTF recommendations at the health plan (payer) level, which may be more effective in impacting usage at the physician level.

This project provides the Task Force with important insights about the level of integration of the USPSTF recommendations in different types of health plans. By presenting the perspectives of health plan staff from a closed-panel, open-panel, governmental, and hybrid health plan, this study offers unique insights into how the USPSTF recommendations are integrated into different types of health plans. Through this report, we intend to present the multi-faceted challenges that health plans face in adopting and delivering the USPSTF recommendations, and offer suggestions for improving dissemination of the recommendations.

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Structure of the Report

NORC's overall approach to this evaluation is described in Section II: Study Methods. Section III provides background information, including a review of the relevant literature on the USPSTF and clinical preventive services.

Section IV presents a detailed discussion of the study findings, exploring the research questions posed in the evaluation design. The findings are organized according to three broad areas. The first, "Adoption of the USPSTF Recommendations in Health Plans," explores respondents' familiarity with the USPSTF recommendations for clinical preventive services and the tools and products it produces, as well as the process by which the health plans review, adopt, and integrate clinical preventive services recommendations. The second, "Integration and Delivery of the USPSTF Recommendations in Health Plans," reports on the bulk of the systems-level characteristics related to clinical preventive service delivery across the health plans, including: the integration of recommendations into practice, the use of health information technology, the use of quality improvement strategies, the impact of reimbursement and performance measurement, perceptions of the USPSTF recommendations, as well as a section on barriers to adoption and integration of recommendations. Finally, the third area, "Improving Dissemination of the USPSTF Recommendations in Health Plans," contains suggestions for improving the utility of the recommendations and for tools and methods that AHRQ could employ to improve the dissemination of the USPSTF recommendations.

While a detailed discussion of the findings is provided in Section IV, Section V takes the evaluation findings a step further by exploring several of the most interesting and important cross-cutting themes. Specifically, this section presents five thematic overviews that analyze themes related to the adoption, integration and delivery, and dissemination of the USPSTF recommendations. Each thematic overview explores a single theme, synthesizing published and unpublished literature and the interviews to present top-level conclusions and to suggest areas for further research. The thematic overviews include: the impact of pay-for-performance; the role of health information technology; the need for systems changes in health plans; the impact of health plan structures; and the challenges associated with delivering the USPSTF recommendations in a rural health care setting. Finally, Section VI presents overall lessons learned, suggested next steps, and key issues for future study.

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