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.
Alcohol Abuse; Hazardous and Harmful Drinking Screening and Brief Counseling (Level I)
Service
Providers must 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 [R]
Screening can be done by using a validated questionnaire such as AUDIT, which detects hazardous or harmful alcohol use and is more amenable to brief interventions [C].
Other questionnaires, especially the four-question CAGE-AID [C]) are primarily designed to identify patients with dependence or abuse, and do not include questions about the quantity or frequency [C].
See Appendix B, "Alcohol and Drug Use/Abuse Screening Tool" in the original guideline document for the AUDIT Structured Interview and CAGE-AID Questionnaire.
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" [M]. A standardized review of the clinically preventable burden and cost effectiveness of 25 preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) found this service to have the fourth highest priority score and one of only six services that were actually cost-saving from a societal perspective. Additionally, the study demonstrated that problem drinking screening and brief interventions in primary care are one of the most effective and cost effective clinical preventive services. It ranks very close to tobacco cessation counseling, yet it is one of the least commonly delivered [M].
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 and avoid binge drinking.
- 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.
Related Guidelines
The NGC summary of the ICSI guideline Primary Prevention of Chronic Disease Risk Factors.
Aspirin Chemoprophylaxis Counseling (Level I)
Service
Aspirin prophylaxis must 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.
Efficacy
The U.S. Preventive Services Task Force recommends a discussion of aspirin therapy for primary prevention of myocardial infarction with patients at risk of CHD [M].
Although the U.S. Preventive Services Task Force 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 [R].
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 [M].
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.
Breast Cancer Screening (Level I)
Service
Screening mammogram must be performed every 1 to 2 years 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
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" [M]. This extension to the 40- to 49-year-old group has been controversial.
The evidence for mortality reduction for low-risk women of this age group is inconclusive. Therefore routine screening of women age 40-49 is left to the judgment of the individual medical groups, clinicians and their patients.
Related Guidelines
The NGC summary of the ICSI guideline Diagnosis of Breast Disease.
Cervical Cancer Screening (Level I)
Service
All women should be screened for cervical cancer beginning at age 21 or three years after initiating sexual intercourse, whichever is earlier [R]. Screening should be performed every three years after three consecutive normal Pap smears over five years [M], [R].
Women age 65 and older who have a new sexual partner should resume routine screening.
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.
Human papillomavirus (HPV) testing may be used as an adjunct to Pap smear screening to help minimize unnecessary colposcopies and other interventions [C]. The role of HPV testing has been expanding [A], [C] and will continue over the next few years. The work group will continue to review new evidence.
Efficacy
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.
Related Guidelines
The NGC summary of the ICSI guideline Initial Management of Abnormal Cervical Cytology (Pap Smear) and HPV Testing.
Chlamydia Screening (Level I)
Service
Routine screening for chlamydia must be performed for all sexually active women aged 25 years and younger and older women at increased risk for infection [M], [R].
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 sensitivity of available screening tests for chlamydia infection is 80% and higher [M]. The U.S. Preventive Services Task Force does not recommend a specific screening test as studies have generally been performed in ideal circumstances in small populations with high prevalence rates. However, they concluded that nucleic acid amplification tests had higher sensitivities and specificities than older antigen detection tests and better sensitivities than culture [M]. Following detection, treatment with antibiotics approaches 100% efficacy. Two randomized studies have observed a decrease in pelvic inflammatory disease following Chlamydia screening [A], [C].
Colorectal Cancer Screening (Level I)
Service
Colorectal cancer screening must be performed in average-risk patients 50 years of age, or 45 years of age and older for African Americans. No older age limit has been clearly established, although 80 has been suggested. The decision to stop screening would clearly be influenced by comorbidities, patient preferences and expected life span (at least 8 to 10 years to warrant continued screening).
Efficacy
Criteria for routine screening for colorectal cancer:
- 50 years old or if African American, 45 years old [R]
- No personal history of polyps and/or colorectal cancer
- No personal history of inflammatory bowel disease [R]
- No family history of colorectal cancer in:
- One first-order relative diagnosed before age 60, or
- Two first-order relatives diagnosed at any age [B]
- No family history of adenomatous polyps in:
- One first-order relative diagnosed before age 60
(A single first-degree relative diagnosed with colorectal cancer after age 60 may put an individual at a slightly increased risk and may warrant starting colorectal cancer screening at age 40. A single first degree relative with an adenomatous polyp diagnosed after age 60 may put the individual at a slightly increased risk and may also warrant starting colorectal cancer screening at age 40 [C].)
Tests to primarily detect cancer
- Stool testing
- Guaiac-based fecal occult blood testing (gFOBT) annually
- Fecal immunochemical testing (FIT) annually
- Stool deoxyribonucleic acid testing (sDNA), interval unknown
Tests to detect adenomatous polyps and cancer
- 60 cm flexible sigmoidoscopy every five years with or without stool test for occult blood annually
- Double-contrast barium enema every five years
- Computed tomography (CT) colonography every five years
- Colonoscopy every ten years
The ICSI Colorectal Cancer guideline (see NGC summary) summarizes the evidence for the effectiveness of the various screening tests commonly used for colorectal cancer screening.
Related Guidelines
The NGC summary of the ICSI guideline Colorectal Cancer Screening.
Hypertension Screening (Level I)
Service
To detect and monitor hypertension, blood pressure must 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 [R].
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 [M], [R].
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 [R].
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 [M], [R].
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 [C], [R].
Related Guidelines
The NGC summary of the ICSI guideline Hypertension Diagnosis and Treatment.
Influenza Immunization (Level I)
Service
Immunization must be provided annually throughout entire flu season for all persons who wish to decrease the likelihood of contracting influenza.
Related Guidelines
The NGC summary of the ICSI guideline Immunizations.
Lipid Screening (Level I)
Services
A fasting cholesterol fractionation (total cholesterol, calculated low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglyceride) must be done 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 [A], [B], [M], [R].
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 [R].
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 coronary artery disease (CAD), PVD, and/or CVD should also be aggressively managed for dyslipidemia [R].
Related Guidelines
The NGC summary of the ICSI guideline Lipid Management in Adults.
Pneumococcal Immunization (Level I)
Service
High-risk groups must be immunized 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.
Related Guidelines
The NGC summary of the ICSI guideline Immunizations.
Tobacco Use Screening and Brief Intervention (Level I)
Service
Providers must establish tobacco use status for all patients [R]. All forms of tobacco should be screened. Provide ongoing cessation services to all tobacco users at every opportunity [R].
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 [R].
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 [R].
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 [A]. The addition of telephone-based counseling may result in further improvements in cessation [A]. Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.
Counseling Messages
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 clinical staff is organized to provide these services.
Related Guidelines
The NGC summary of the ICSI guideline Primary Prevention of Chronic Disease Risk Factors.
Vision Screening (Level I)
Service
Objective vision testing (Snellen chart) for asymptomatic patients must be provided only for older adults. The work group concurs with the U.S. Preventive Services Task Force conclusion that there is insufficient data to recommend a specific screening frequency. Limited data on progression of vision loss suggests that screening once every 2 to 10 years is reasonable. For purposes of performance measurement, screening frequency is specified as once every five years.
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. Inadequately corrected vision can become a barrier to care.
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 [R]. These summary estimates include only one U.S. study [C], but are generally consistent with other U.S. studies [A], [B], [C].
