Section 7. Formulation of Task Force Recommendations
7.1 General Principles for Making Recommendations
7.1.1 All recommendations are based on a body of scientific evidence that is derived from systematic evidence reviews and can use modeling to inform the process and make decisions after full consideration of the certainty and magnitude of net benefit (Section 5).
Evidence may come from indirect evidence in the analytic framework, but ultimately the complete chain (linking populations with health outcomes) must be supported by acceptable evidence.
Inferences about supporting evidence can include generalizations from one population to other subgroups when there are acceptable grounds to assume the evidence is applicable to both.
The Task Force invites and considers the opinions of the public and experts throughout the recommendation development process, including the draft evidence review and the draft recommendation statement. The Task Force is particularly interested in receiving comments on the sufficiency of the systematic review process and interpretation of the body of evidence. However, expert opinion and clinical experience cannot substitute for the body of evidence that the Task Force reviews through a systematic process.
Recommendations describe services that should or should not be routinely offered based on scientific evidence, although it is recognized that in clinical practice and public policy, concerns other than scientific evidence (e.g., feasibility, public expectations) may take precedence.
7.1.2 When making recommendations, the Task Force considers most strongly patient-oriented health benefits and harms.
In assessing health benefits, outcomes that patients can feel or care about (e.g., pain, quality of life, disease-specific death, overall mortality) receive more weight than intermediate outcomes.
In judging the magnitude of benefit, absolute reductions in risk matter more than relative risk reductions.
Evidence for service effectiveness is considered as valuable as, if not more valuable than, efficacy. The ability of patients, providers, and the health care system to perform or maintain interventions over time is considered. The direct and indirect harms of preventive services must also be considered, ensuring that they do not outweigh the benefits to the individual and/or population. The quality of evidence for harms need not be as strong as that for benefits because of the ethical imperative to do no harm, especially when caring for asymptomatic persons. Physical, psychological, and social harms are considered.
Judgments about tradeoffs between benefits and harms are generally made at the population level. For interventions where the relationship between benefits and harms is influenced heavily by personal preferences, the Task Force advocates that providers and patients engage in shared decisionmaking.
Consideration of benefits and harms should not be limited to the perspective of individuals but should also consider population effects (e.g., population attributable risk, decreased exposure to infectious diseases, herd immunity).
7.1.3 The USPSTF does not consider the financial costs of providing a service in its assessment of the balance of benefits and harms, but may provide contextual information regarding costs for use by providers, including cost-effectiveness studies.
7.1.4 Recommendations apply only to persons without signs or symptoms of the condition for which the preventive service is intended.
Persons living in the United States are the target population for all recommendation statements. The evidence reviews and recommendations may be useful in other countries, but may not apply to populations with markedly different epidemiology and health care system design.
7.1.5 Recommendations apply only to preventive services that are delivered in or are referable from the primary care setting to a specialist or community resource.
The evidence for preventive services delivered outside the primary care context (e.g., programs at schools, worksites, public health sites) is usually out of scope unless these services are linked to primary care.
7.2 Recommendation Grades
The Task Force applies grades to all of its recommendations and may issue multiple grades on a topic to address specific subpopulations. The Task Force can issue a grade of A, B, C, or D, as described in Table 4. When evidence is insufficient to make a recommendation, the Task Force issues an "I statement."
|Grade||Definition||Suggestions for Practice|
|A||The USPSTF recommends the service. There is high certainty that the net benefit is substantial.||Offer or provide this service.|
|B||The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.||Offer or provide this service.|
|C||The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.||Offer or provide this service for selected patients depending on individual circumstances.|
|D||The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.||Discourage the use of this 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.||Read the Clinical Considerations section of the USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.|
After full consideration and decision on both certainty and magnitude of net benefit, the topic leads discuss the appropriate grade for the service in the targeted population, using the scoring matrix in Table 5.
|Certainty of Net Benefit||Magnitude of Net Benefit|
The Task Force values consistency in our process for determining grades. Changes in the grade when updating a previously published recommendation should have a strong rationale that stems directly from our process of determining grades (i.e. there is a difference in certainty or magnitude that warrants a change in grade). After the leads discuss the adequacy of the evidence on calls leading to the vote at the Task Force meeting, the leads identify any grade changes and discuss the rationale for proposed grade change.
A grade may result in a change from a previous Task Force recommendation because of one or more of the following: 1) a change in methods and/or analytic framework since the last recommendation statement; 2) a change in the definition of a grade (i.e. change in C grade definition); 3) evidence has increased or decreased and results in a change in the certainty or magnitude of net benefit, or has made the issuance of a grade less relevant. This may occur when there is a change in our understanding about the applicability of older evidence or international evidence; 4) new methods and/or new evidence regarding subpopulations. The Task Force strives to avoid a narrow "I statement" for a subpopulation when there is a grade for the overall population and no strong rationale exists that the subpopulation would be different from the larger population. Grade changes may also result from changes in context (clinical context, societal values for specific outcomes, and context of intervention and treatment). In this case, while the analytic framework is largely similar to the prior framework, something has changed in the contextual issues. It is important that the Task Force communicate in its recommendation statement how the changes in the above factors or context affect our rating of certainty and magnitude and why this results in a grade that is different than a previously published grade.
Before the grading discussion, the Task Force is provided with an oral presentation summarizing the evidence to supplement the full evidence review provided by the EPC. Following clarification of any questions regarding the evidence, the Task Force then hears from the topic leads regarding their proposal for a grade. After full debate and consideration of grading options, the Task Force Chair calls for a motion for a draft recommendation grade (go to Section 7.4 for voting procedures). The leads refine the draft recommendation with final language before it is released for public comment (go to Section 9 for more information on public comment).
To help readers better understand the Task Force's judgment about the certainty of the evidence, the net benefit of implementation, and the overall recommendation about the use of each preventive service, the Task Force provides its rationale and statements about clinical considerations in the recommendation statement. While an "I statement" is considered a statement and not a recommendation, these topics are accompanied by the same type of rationale and clinical considerations as grade A, B, C, or D recommendations.
For clarity, consistency, and usability, Task Force recommendations follow a standard, structured format.
Each recommendation statement is also accompanied by a one-page clinical summary, which provides a table of key information about the recommendation, including the population of interest, recommendation, risk assessment, screening or intervention of interest, treatment, balance of benefits and harms, and other relevant USPSTF recommendations.
A fact sheet for each recommendation is also prepared for consumers. The Task Force also produces additional fact sheets, summary tables, infographics, and videos when appropriate to further explain recommendations to diverse audiences.
7.3 Process for Public Comment on Task Force Documents
To increase the clarity, transparency, and utility of its recommendation statements to primary care providers and the public, the Task Force shares drafts of its research plans, evidence reviews, and recommendation statements for public comment. The comments are considered in finalizing the documents. The procedures for posting draft materials for public comment are described in Section 9.
All comments received through the public comment process are shared with the topic leads for their review and consideration before finalizing the document. All Task Force members have access to the full text of all comments; a disposition table summarizing the comment themes and the proposed Task Force response; and the revised research plan, evidence review, or recommendation statement.
Formal votes are taken for major procedural and methodological decisions, for draft recommendations before posting, for final recommendations, and for statements about clinical practice. Votes may be taken for other decisions at the discretion of the Chair(s).
7.4.1 General Voting Procedures
All motions on recommendations (at any stage) requiring a vote are passed when two thirds of the current Task Force membership vote "yes." Votes are taken by voice, hand, or email, without secret ballots.
Motions on procedural, methodological, and other decisions requiring a vote are passed when a majority of current Task Force membership votes "yes."
Votes are submitted as yes, no, abstain, or absent.
Members recused by reason of potential conflict of interest are recorded as recused and do not vote.
In votes that are less than unanimous, there are no minority reports.
The result of a vote is recorded in the meeting minutes, though the count of "yes," "no," and "abstain" votes is not recorded.
7.4.2 Voting on Draft Recommendations
At a meeting of the full Task Force (usually in person), the presiding Chair accepts motions for draft recommendations. A "yes" vote from two thirds of the current Task Force membership is needed to pass the motion. After the meeting, the topic leads draft the full recommendation statement, and it is posted for public comment.
7.4.3 Motion to Reconsider a Draft Recommendation Already Voted Upon
A vote to reconsider a motion on a draft recommendation is required if the topic leads or any other Task Force member would like to request consideration for a change in the grade of the draft recommendation that was voted by the full Task Force. In this case, the individual member or the primary topic lead speaks with the Chairs, requests a vote to reconsider, and, if passed (requiring a "yes" vote from two thirds of the current membership), makes a new motion. The Chair then calls for a vote (which may take place via conference call or email after several days of reflection and discussion). A "yes" vote from two thirds of the current Task Force membership is needed to pass the motion on the new draft recommendation. If the motion to approve a reconsidered recommendation fails to pass, the approval reverts back to the originally approved recommendation.
7.4.4 Voting on Final Recommendations
After consideration of public comments, the topic leads puts forward a new motion for consideration by the full Task Force for the final recommendation. If the final recommendation statement is similar to the posted draft, debate is limited, and the full Task Force votes via email. A "yes" vote from two thirds of the current Task Force membership is needed to pass the motion and ratify the final recommendation.
If, as a result of the comment process or new evidence identified during the public comment period, any member of the Task Force believes that a change in the recommendation grade is warranted, he or she can request that the topic leads make a motion to the Task Force. At that point, any new evidence is reviewed by the topic leads with help from AHRQ and the appropriate EPC staff. The AHRQ Medical Officer and Scientific Director facilitate this process. The topic leads present their motion and any important new evidence to the full Task Force (most often via conference call or Webinar), followed by time for discussion. The Chair then calls for a vote on the motion (which may take place via email after several days of reflection and discussion). This approach recognizes that the vote on the final recommendation is a different motion than the vote on the draft (hence two separate motions and votes). A "yes" vote from two thirds of the current Task Force membership is needed to pass the motion and ratify the final recommendation.
7.5 Dissemination Process and Products
Task Force recommendations are widely disseminated to professional audiences in professional peer-reviewed journals, in an electronic tool (electronic Preventive Services Selector [ePSS]) available online or as a mobile application, in print through the "Guide to Clinical Preventive Services," and as reprints in peer-reviewed journals, such as American Family Physician. Tools for clinicians, including ePSS, are available on the Task Force Web site at www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care.
AHRQ's Center for Evidence and Practice Improvement is committed to improving the health of all Americans by working to make sure that everyone in the health care system—clinicians, consumers, providers, and payers—knows about and uses these evidence-based clinical preventive services.
To achieve this goal, AHRQ's Center for Evidence and Practice Improvement works with public and private partners to reach specific groups and individuals with information about appropriate clinical preventive services, their benefits, and how to improve access to and use of these services.
Internet Citation: Section 7. Formulation of Task Force Recommendations. U.S. Preventive Services Task Force. July 2017.