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U.S. Preventive Services Task Force

U.S. Preventive Services Task Force (USPSTF) Procedure Manual (continued)

Section 2: Topic Selection, Prioritization, and Updating

The USPSTF has a large library of current topics and frequently receives nominations for new topics. The overall goal for new topic selection and prioritization is to provide accurate and relevant recommendations that are as up to date as possible and to balance the overall portfolio of recommendations by populations, types of services (screening, counseling, preventive medications), disease types (e.g., cancer, endocrine disease) and size of project (e.g., 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 Guideline Clearinghouse™, an AHRQ-initiated public resource for evidence-based guidelines (http://www.guideline.gov). The criteria for new topic selection and for prioritization (discussed in detail below) are combined in an assessment of the topic as a whole, rather than used as part of a scoring system.

2.1 Topic Types and Definitions

There are two types of topics in the Task Force library: active and inactive. Among the active topics, there are four categories for consideration: new, updated, reaffirmed, and referred; each of these categories is defined below. The processes for developing work plans, assessing evidence, and making recommendations for active topics are discussed in Sections 3, 4, and 5.

Active Topic Types

New topics are topics chosen by the USPSTF for review and recommendation that have not been previously reviewed.

Updated topics are topics reviewed in the past by the USPSTF that have since undergone an update of the evidence and recommendation. The update may encompass all key questions on a topic (full update) or only a limited set of the key questions in the analytic framework (targeted update).

Reaffirmed topics are topics kept current by the USPSTF 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 in its library of preventive services, it has determined that only a very high level of evidence would change the recommendation. Only recommendations with a current grade of A or D are considered for reaffirmation. The procedure for reaffirming a topic is discussed in Section 4.

Referred topics are topics in which the USPSTF refers providers to another organization's recommendation. These topics were originally maintained by the Task Force and are retained as active in the Task Force library; however, the Task Force has determined that there is another organization (e.g., Centers for Disease Control and Prevention's [CDC's] Task Force on Community Preventive Services) with evidence-based methods that is better positioned to make accurate and timely recommendations for this topic. The procedure for referring to other organizations is discussed in Section 2.5.

Inactive Topics

Inactive topics are topics the USPSTF has decided to inactivate (e.g., electronic fetal monitoring, home uterine monitoring, and counseling for dental disease) for one or more reasons (go to Section 2.4).

2.2 New Topic Prioritization and Selection

The Task Force solicits new topics for consideration through a periodic notice in the Federal Register (go to Appendix V) and solicitation of professional liaison organizations, including, but not necessarily limited to, the USPSTF's partner organizations. New topic nominations may also be submitted by USPSTF members, members of the public, or others on an ongoing basis, outside of the Federal Register notice.

Topic nominations are first considered by the USPSTF's Topic Prioritization Workgroup, which then recommends a selection and prioritization of new topics to the entire Task Force.

The entire Task Force ultimately votes on the selection and priority of new topic nominations. The Topic Prioritization Workgroup receives support from AHRQ staff in gathering background information to facilitate topic selection and prioritization.

The USPSTF first considers whether newly nominated topics are within the scope of the USPSTF (that is, whether the topic relates to a primary or secondary preventive service that is relevant to primary care, and whether the topic address a disease with a substantial health burden). Topics that meet these first two criteria are then prioritized using the following specific criteria:

  1. Public health importance (i.e., burden of suffering and expected effectiveness of the preventive service 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).

2.3 Prioritization and Selection of Active Topics

The Topic Prioritization Workgroup begins prioritization of an active group of topics 2 years after their previous publication.

Step 1. AHRQ staff creates a 1- to 2-page background paper on the topic that includes the following information: previous recommendation statement, estimate of disease burden, relevance to prevention and primary care, existing controversy, and summary of a brief literature search for new evidence.

Step 2. The Topic Prioritization Workgroup reviews and discusses the background paper and places each topic into either the active or inactive category. Topics that are retained as active are considered for referral to other organizations. Go to Section 2.5 for the process of referring a topic. Go to Section 2.4 for the process of inactivating a topic.

Step 3. AHRQ staff prepares a request for feedback on all of the remaining active topics to be sent to USPSTF members, partner organizations, and other appropriate stakeholders. Respondents are asked to categorize each proposed topic as high, moderate, or low priority for review in the next 12-18 months, based on the following criteria:

  1. Public health importance (i.e., burden of suffering and expected effectiveness of the preventive service 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).
  3. New evidence (e.g., new studies or new analyses of previous data) that has the potential to change prior recommendations.
  4. Need for a balanced portfolio of topics.

Step 4. The feedback from USPSTF members, partner organizations, and stakeholders is considered by the Topic Prioritization Workgroup, along with the background paper, in assigning a draft priority category for active topics. The Topic Prioritization Workgroup also reviews and updates the priority of all other active topics (i.e., not currently under review) that have not been referred. The four criteria listed in Step 3, along with resource requirements for the review, are used to recommend priority (low, moderate, or high).

Step 5. The topic categorization and prioritization becomes final after a vote of the full USPSTF membership.

Steps 1-5 are repeated every 5 years (i.e., 7 years after publication) for topics that have not already been placed in the work queue) (Figure 1a).

AHRQ staff develops the work queue for the next 12- to 18-month cycle using the priority level determined by the USPSTF. Other factors that may be used by AHRQ staff in determining the work queue include: availability of research team, availability of review or funds from a non-USPSTF source, efficiency of combining reviews or research teams on related topics, impending release of relevant study, and age of relevant non-USPSTF review.

2.4 Inactivating a Topic

Inactive topics are topics the Task Force has decided to inactivate (e.g., electronic fetal monitoring, home uterine monitoring, and counseling for dental disease) for one or more of the following reasons:

  1. Topic is 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. Topic is 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.
  3. Topic has a low public health burden.
  4. Topic is otherwise outside of the USPSTF's scope.

Previously inactivated or referred topics are also eligible as new topic nominations, if appropriate, along with other new topic suggestions.

If a topic is inactivated or referred to another organization, the status on the USPSTF Web site continues to be listed as "active" for a minimum of 5 years from the date of the original recommendation, unless considerations arise beforehand to change the status. After this period, the status changes to "inactive" or "referred."

2.5 Referring a Topic to Other Organizations

The recommendations for some topics in the USPSTF library may be referred to another organization that the Task Force believes is in a better position to make an accurate and timely evidence-based recommendation. This practice avoids redundancy of resource use by the USPSTF. An example is the Advisory Committee on Immunization Practices (ACIP), a non-Federal panel of immunization experts convened by the CDC. In the past, the Task Force has referred recommendations on immunizations to the ACIP. Another example is the CDC's Task Force on Community Preventive Services, which makes evidence-based recommendations on many health promotion topics. The organization identified for referral should have the resources for timely updates of the evidence and a scientifically acceptable methodology for its evidence reviews (see the list of criteria below). Other than immunizations, the Task Force anticipates that few topics will fall into this category. The process for designating a topic for referral is as follows:

  1. The Topic Prioritization Workgroup identifies a potential outside organization that makes evidence-based recommendations and decides to consider the topic for referral.
  2. AHRQ staff reviews the previous Task Force recommendation statement and evidence report.
  3. AHRQ staff reviews the recommendations and review methods of other Federal agencies and professional organizations.
  4. AHRQ staff prepares a brief summary of why the topic has been chosen for referral, a reference to 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 Topic Prioritization Workgroup decides whether to proceed with a full Task Force discussion.
  6. If the Topic Prioritization Workgroup 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 refer the topic to the specific organization.
  7. AHRQ staff adds a single summary paragraph to the USPSTF Web site that includes a link to the organization's recommendation.

Referred topics may be re-activated through the usual new topic nomination process (go to Section 2.2). The criteria for referring to another organization's recommendation are:

  1. The organization has been identified by the USPSTF as an appropriate source.
  2. The organization has a process for updating recommendations in a timely manner.
  3. The organization has a written and available evidence-based methodology, including the use of systematic reviews that assess benefits and harms, that the Task Force judges to be adequate for the topic.

2.6 Consideration of an Early Topic Update

Occasionally a study will be published after a recommendation's release that may potentially affect the USPSTF's consideration of the evidence and its conclusions about the certainty and/or magnitude of the net benefit (and the recommendation itself). These studies are brought to the attention of the USPSTF by a number of sources, including the public, USPSTF members, Evidence-based Practice Centers, professional organizations (including USPSTF partners), and advocacy groups. In addition, the USPSTF actively surveys the literature to ensure that the Task Force is aware of new evidence in a timely manner. The process for this active surveillance is discussed in Appendix III. The Task Force uses the following process to consider new evidence and decide whether a recommendation needs to be updated earlier than the usual 5-year timeframe:

  1. The USPSTF Program Director at AHRQ is notified of the new evidence and assigns an AHRQ Medical Officer to review the study. Ideally, the Medical Officer who reviews the evidence is the same Medical Officer who performed the previous review. The Medical Officer fills out a review form with the following information:
    • Citation.
    • Nominator, affiliation.
    • Assigned Medical Officer.
    • Brief summary/abstract of study.
    • Number of criteria met (see below).
    • Recommendation of Medical Officer/Program Director.
    • Summary of Topic Prioritization Workgroup and Task Force discussion (to be completed later in the process).
    • Action/disposition (to be completed later in the process).
    Criteria for evaluating evidence to trigger an early review (order is not necessarily based on criteria weighting):
    • New evidence that conflicts with current recommendation.
    • Large-scale study that may improve certainty of net benefit.
    • Potential that new evidence will change recommendation grade.
    • Evidence on a new intervention/strategy not previously considered.
    • Change in magnitude of benefit or harm that might alter magnitude of net benefit.
    • Potential of evidence to fill gap in the chain of indirect evidence.
    • Existing controversy about topic.
    • Public health burden of condition.
    • Quality, relevance, or type of study (e.g., a randomized, controlled trial is published on a topic for which the current recommendation is based on observational evidence).
    • Published in peer-reviewed journal.
    • Evidence that directly links the prevention strategy to the primary outcome of interest (i.e., direct evidence of health effect).
    • Source of identification of the new evidence (e.g., professional organization, Task Force member, advocacy group).
  2. The form and the Medical Officer's recommendation is sent to the Program Director and the AHRQ lead in the Topic Prioritization Workgroup.
  3. If appropriate, a discussion of the evidence is placed on the agenda for the Topic Prioritization Workgroup's monthly conference call. If there is an identified current USPSTF member who is a topic lead or expert in the subject area and who is not a member of the Workgroup, then that Task Force member is invited to participate in the conference call. The evidence and the review form are sent to the call attendees with an agenda.
  4. The Topic Prioritization Workgroup discusses the evidence and, using the criteria defined above, makes a recommendation to the entire Task Force about whether the evidence should trigger an early update of the review.
  5. The USPSTF votes at its next meeting on whether the evidence update should be accelerated due to the new evidence. The Task Force also assigns a priority level (high, moderate, low) based on the usual topic prioritization criteria.
  6. If the USPSTF decides to accelerate the update, the USPSTF Program Director at AHRQ places the topic in the review queue.
  7. A brief notice from the USPSTF Chair is sent to the nominator about the disposition.

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