First Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services - II
Table of Contents
- Executive Summary
- I. Introduction
- II. Background
- III. Role of USPSTF in Clinical Prevention
- IV. Major Activities of the USPSTF in 2010–2011
- V. Current Evidence Gaps Deserving of Further Research
- High-Priority Evidence Gaps for Screening Tests
- High-Priority Evidence Gaps for Behavioral Interventions
- High-Priority Evidence Gaps in Clinical Preventive Services Targeting Specific Populations and Age Groups
- VI. Next Steps for the USPSTF in 2012
- Appendix A. 2011 Members of the USPSTF
- Appendix B. USPSTF Partner Organizations
- Appendix C. Complete Listing of All USPSTF Specific Recommendations as of September 2011
Certain clinical preventive health care services can have tremendous public health importance. When provided appropriately, they can identify diseases at early, more treatable stages or lower a patient's risk of developing a disease altogether. However, preventive services can also fail to provide the expected benefit or may even cause harms. To make informed decisions, patients and health care providers need access to trustworthy, objective information about the benefits and harms of clinical preventive services.
Established in 1984 by Congress, the USPSTF is an independent panel of nonfederal experts in prevention and evidence-based medicine. The Task Force carefully assesses the evidence and makes recommendations about preventive services such as screening tests, counseling services, or preventive medications that are provided in clinical settings, and are intended to prevent disease or improve health outcomes from heart disease, cancer, infectious diseases, and other conditions and events that affect the health of children, adolescents, adults, older adults, and pregnant women. The Agency for Healthcare Research and Quality (AHRQ) provides scientific, technical, logistical, and dissemination support to the USPSTF.
Complementing the work of the USPSTF, preventive services at the community level are addressed by the Community Preventive Services Task Force (CPSTF), which was established in 1996 by the U.S. Department of Health and Human Services. The CPSTF assists agencies, organizations, and individuals at all levels (national, State, community, school, worksite, and health care system) by providing evidence-based recommendations about community prevention programs and policies that are effective in saving lives, increasing longevity, and improving Americans' quality of life. The work of the CPSTF is supported by the Centers for Disease Control and Prevention. A diagram outlining the complementary domains of the USPSTF and the CPSTF is shown in Figure 1.
Who Serves on the Task Force?
The USPSTF comprises 16 volunteer members who are nationally recognized experts in the disciplines of preventive medicine and primary care, including internal medicine, family medicine, geriatrics, pediatrics, preventive medicine, behavioral medicine, public health, obstetrics and gynecology, and nursing (go to Appendix A for a current roster of members). All members volunteer their time to serve on the USPSTF, and most are practicing clinicians.
USPSTF members are appointed by the Director of AHRQ and serve a 4-year initial term. Members must have no substantial conflicts of interest that could impair the scientific integrity of the work of the Task Force. For each preventive service under consideration, the financial, professional, and intellectual activities of Task Force members are evaluated to identify any conflicts of interest that would require a member to recuse him- or herself from participation in the review of that topic.
What Does the Task Force Do?
The USPSTF makes recommendations on clinical preventive services, based on scientific evidence about the effectiveness of each service. These recommendations are primarily directed to the primary care professional who delivers these services. USPSTF recommendations are also used by individuals and families as they make decisions about their own health and health care, and by health care organizations as they consider their policies. USPSTF recommendations apply to preventive services that are offered in a primary care setting (such as a Pap smear to detect cervical cancer), services that are available through primary care referral (such as a colonoscopy to detect colorectal cancer), or behavioral counseling programs (such as counseling to help reduce obesity). USPSTF recommendations apply to people who have no signs or symptoms of a disease or condition.
Every USPSTF recommendation is based on a rigorous, systematic review of the scientific evidence published in peer-reviewed journals. To make its recommendations, the USPSTF evaluates the potential benefits and harms of clinical preventive services. When appropriate and when evidence exists, the Task Force evaluates the potential benefits and harms based on age, sex, and risk factors for disease. The potential benefits of preventive services include early identification of disease and improvement in health outcomes. The potential harms of preventive services can include adverse effects of the service itself or inaccurate test results that lead to a cascade of additional testing, some with attendant risks, or unneeded treatment.
The USPSTF evaluates the balance of the potential benefits of a service against the harms and assigns a letter grade. Clinical preventive services graded "A" or "B" are those services for which the USPSTF has determined that the potential benefits of the service outweigh its potential harms. Services with a grade of "D" are those whose potential harms outweigh the benefits. A grade of "C" indicates that the balance of benefits and harms is a close call. The Task Force also issues "I" statements when the evidence is insufficient to determine the balance of benefits and harms.
Table 1: USPSTF Grades Explained
|A||The USPSTF recommends the service.|
|B||The USPSTF recommends the service.|
|C||[The following statement is undergoing revision]
Clinicians may provide the service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms, there is likely to be only a small benefit from the service.
|D||The USPSTF recommends against the service.|
|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.|
USPSTF Recommendation Statements: What Do They Mean and How Are They Used?
When it makes a recommendation, the USPSTF issues a Recommendation Statement that includes the rationale for the recommendation, clinical considerations, other considerations (including research needs and gaps), a discussion of the evidence, and the recommendations of other organizations or entities. Recommendation Statements provide information based on the best available evidence and support shared decisionmaking by clinicians and patients. When supported by the evidence, Task Force recommendations provide specific information regarding the timing and frequency of services and whether these differ based on risk characteristics. However, evidence of this type is not always available, and in such cases, the USPSTF, as a science-driven body, chooses not to comment on timing or frequency, and may instead identify these areas as important gaps to be addressed by future research.
The USPSTF makes its recommendations based on its assessment of the effectiveness of each clinical preventive service. The Task Force does not explicitly consider costs in its appraisal of the effectiveness of a service. The USPSTF recognizes that insurance coverage decisions involve considerations in addition to the scientific assessment of the clinical benefit and harms alone.
Steps in Making a USPSTF Recommendation
The USPSTF regularly prioritizes new clinical preventive service topics and topics for updating based on public input and new evidence. The steps that the USPSTF takes once a topic has been selected for review are shown in Figure 2. The Task Force aims to update prioritized topics every 5 years.
(The USPSTF Procedure Manual serves as a full guide to the methods of the Task Force and is publicly available at http://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual.)
Since it began its work, the USPSTF has considered primary care clinicians the main audience for its recommendations. The medical literature that is the basis for the recommendations of the USPSTF provides evidence regarding the potential benefits and harms of clinical preventive services for large groups of people or populations. This type of information is useful to primary care clinicians and health systems when they consider how to provide care and organize their practices to produce the greatest health benefits. The USPSTF recognizes that skilled clinicians serve their patients by individualizing recommendations based on evidence from large groups of people to the specific circumstances, values, and perspectives of the individual patient. The USPSTF also recognizes the complexity involved in "translating" population-based recommendations to the specific care of individuals and has recently embarked on active efforts to make its population-based recommendations more easily understandable by the public.
USPSTF Engagement With Partners and the Public
AHIP and our member health insurance plans believe that the Task Force is the gold standard of evidence-based recommendations around preventive services. Karen Ignagni, President & Chief Executive Officer, America's Health Insurance Plans
The USPSTF is committed to making its work as transparent as possible—both in terms of increasing stakeholders' and the public's understanding of and confidence in the approach of the USPSTF, and in ensuring that its approach is viewed as open, credible, independent, and unbiased. As part of this commitment, the USPSTF is working to provide additional opportunities for stakeholders and the public to engage at multiple points in the recommendation development process and offer feedback to the USPSTF.
The work of the USPSTF has been informed for much of its existence by 22 partner organizations (Appendix B). Partner organizations represent primary care clinicians, consumer organizations, federal agencies, and other stakeholders in the delivery of primary care. Currently, primary care organizations, the principal audience for Task Force recommendations, represent pediatrics, geriatrics, family medicine, preventive medicine, nursing, internal medicine, and osteopathic medicine. Eight federal agencies are partners of the USPSTF, including the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare and Medicaid Services. Partner organizations provide input regarding which preventive services topics will be addressed, provide expert review of evidence reports and Recommendation Statements, and assist with the dissemination of USPSTF recommendations to their members. The breadth of scientific and practical expertise of partner organizations is highly valuable to the Task Force in increasing the usability and clarity of its recommendations.
The USPSTF is also committed to engaging the public and encouraging public comment on its processes and recommendations. Currently, the public can nominate new members and suggest new topics for consideration by the USPSTF at any time via the USPSTF Web site (www.uspreventiveservicestaskforce.org). In addition, all draft recommendations are posted for public comment on the Task Force Web site for 1 month, during which time anyone can provide feedback. All comments received from this process are reviewed by the Task Force and used to revise the final USPSTF Recommendation Statement. In the near future, the USPSTF will begin posting the topic research plans for public comment and posting the resulting draft evidence reports for public review (Figure 3).
Internet Citation: First Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services - II. U.S. Preventive Services Task Force. February 2014.