Clinical Prevention: How to Get it All Done Part I - How John Epling, MD, MSEd, FAAFPChair, Department of Family Medicine Associate Professor, Department ofPublic 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.
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
United States Preventive ServicesTask ForceUSPSTF
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 RecommendationsCertainty of Magnitude of Net BenefitNet Benefit Substantial Moderate Small Zero/ negativeHigh A B C DModerate B B C DLow Insufficient Certainty of benefit = how good is the research evidence supporting the rec. Magnitude of benefit = less disease/death versus harm from procedures, anxiety, etc. http:// www.uspreventiveservicestaskforce.org/uspstf/grades.htm
What the Grades Mean: Suggestions for Practice Grade Suggestions for practiceA Offer or provide this service.BC 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. http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm
Advisory Committee on ImmunizationPracticesACIP
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)