Clinical Prevention:How to Get it All Done

Part I - How

John Epling, MD, MSEd, FAAFPChair, Department of Family Medicine

Associate Professor, Department of Public Health and Preventive Medicine

Objectives

• Clinical preventive service recommendations from the U.S. Preventive Services Task Force and Advisory Committee on Immunization Practices.

• Strengths and limitations of the methodologies employed by the USPSTF and ACIP in making their recommendations.

• Impact of prevention on disease and the barriers to delivery clinical preventive services in family medicine.

• USPSTF and ACIP recommendation through friendly resources.

Disclosures and Disclaimers

• I have received honoraria and expenses for delivering different versions of this talk for an AHRQ contractor.

• I was a 2011-12 AAFP Vaccine Science Fellow, funded with unrestricted educational grant by Merck. Some Merck Vaccines are recommended in the ACIP recommendations.

INTRODUCTION

Prevention today

• More Complex• More based on risk assessment• More cost• How can we manage this?

– Framework– Understanding– Resources/reminders– Risk tools

How can we think about and organize Prevention?

Framework:Categories of Clinical Prevention

• Screening– Mammography– PSA

• Vaccination– Influenza

• Behavioral Counseling– Healthy Eating/Physical Activity/Smoking

• Chemoprophylaxis– Breast cancer prevention, aspirin

Understanding:Rationale for Prevention

• Primary prevention?– Lifestyle risk factors are the “actual causes of death

– smoking, lack of exercise, poor diet, and excessive alcohol use

• Secondary prevention– Finding cancer early – but is this always a good

thing?• Tertiary prevention

– i.e. chronic disease management

Sources of Prevention Information

• Government-sponsored:– US Preventive Services Task Force– CDC’s Advisory Committee on Immunization Practices

• NIH institutes– NHLBI, NCI, NIDDK

• Advocacy Organizations– American College of Cardiology– American Heart Association– American Cancer Society

We must…

• Take prevention seriously• Learn about prevention recommendations• Be creative and diligent about implementing

prevention

USPSTF

United States Preventive Services Task Force

US Preventive Services Task Force

• Commissioned by Congress and staffed by the Agency for Health Research and Quality

• Members are Physicians (primary care), Nurses, Health Behavior Specialists– Independent and knowledgeable in clinical

prevention and appraisal of evidence

Keys to Understanding USPSTF Recommendations

• Preventive services recommendations should have the BEST evidence supporting them – applied to those without symptoms or complaints.

• Cost, insurance, politics, advocacy have no role or influence

• Preventive services can cause harm and recommendations should balance benefits and harms

Keys to Understanding USPSTF Recommendations

• Recommendations can be nuanced and complex

• BUT, with appreciation of evidence, some preparation and a little help from technology – we can assure we’re delivering the best preventive services for our patients

USPSTF Grades of Recommendations

Certainty of Net Benefit

Magnitude of Net Benefit

Substantial

Moderate

Small Zero/ negative

High A B C D

Moderate

B B C D

Low Insufficient

http:// www.uspreventiveservicestaskforce.org/uspstf/grades.htm

Certainty of benefit = how good is the research evidence supporting the rec.Magnitude of benefit = less disease/death versus harm from procedures, anxiety, etc.

What the Grades Mean: Suggestions for Practice

http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm

Grade Suggestions for practice

AOffer or provide this service.

B

C Offer or provide this service only if other considerations support the offering or providing the service in an individual patient.

D Discourage the use of this service.

I statement

Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

ACIP

Advisory Committee on Immunization Practices

Advisory Committee on Immunization Practices – who

• 15 experts in fields associated with immunization• selected by the Secretary of the U. S. Department of Health

and Human Services• Provide advice and guidance to the Secretary, the Assistant

Secretary for Health, and the Centers for Disease Control and Prevention (CDC)

• 8 ex officio members who represent other federal agencies with responsibility for immunization programs in the United States

• 30 non-voting representatives of liaison organizations that bring related immunization expertise.

ACIP - what• provide advice

– reduction in the incidence of vaccine preventable diseases in the United States

– increase in the safe use of vaccines and related biological products. • develops written recommendations for the routine administration of

vaccines to children and adults in the civilian population– age for vaccine administration– number of doses– dosing interval– precautions and contraindications.

• only entity in the federal government that makes such recommendations.

ACIP - How

• Workgroups– Covering specific vaccines/issues– Work presented at meetings until final

recommendation is made• GRADE

– Evidence-based recommendation system– Officially adopted 2011 (October mtg)

• Whole committee discussion and vote

ACIP - How

• Recommendations:– A – general recommendation

• Should get this vaccine• Insurers generally pay for these

– B – “permissive” recommendation• Can get this vaccine• Insurers may not pay.

– Vaccines For Children Program coverage• ACIP authorizes coverage of the vaccine through this

program (children)