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Guideline Summary
Guideline Title
Adult clinical preventive care.
Bibliographic Source(s)
University of Michigan Health System. Adult clinical preventive care. Ann Arbor (MI): University of Michigan Health System; 2011 Dec. 20 p. [15 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

General health

Guideline Category
Counseling
Prevention
Screening
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Obstetrics and Gynecology
Preventive Medicine
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To improve preventive care by providing clinicians a list of indications to use in determining all of the commonly recognized preventive services appropriate for individual patients

Target Population

General adult population in the United States

Note: Issues relevant to the care of pregnant and lactating women are not included. Preventive care (e.g., immunizations) for individuals traveling to other countries is not included.

Interventions and Practices Considered

Screening

  1. Abdominal aortic aneurysm screen (ultrasound)
  2. Alcohol misuse screen
  3. Breast cancer screen (mammogram)
  4. Genetic risk assessment for breast and ovarian cancer and BRCA mutation testing
  5. Cervical cancer screen
  6. Chlamydial infection screen
  7. Colorectal cancer screen
  8. Depression screen
  9. Diabetes mellitus, type 2 screen
  10. Hearing loss screen
  11. High blood pressure screen
  12. Human immunodeficiency virus (HIV) infection screen
  13. Lipid disorders screen
  14. Obesity screen
  15. Osteoporosis screen (bone densitometry)
  16. Syphilis infection screen
  17. Glaucoma screen
  18. Prostate cancer screen (digital rectal examination and prostate-specific antigen [PSA] test)
  19. Family and intimate partner violence screen

Counseling

  1. Calcium and vitamin D intake (counseling and prophylaxis)
  2. Dietary counseling
  3. Sexually transmitted infections counseling
  4. Tobacco use and tobacco-caused disease counseling

Chemoprophylaxis

  1. Aspirin for cardiovascular disease
  2. Breast cancer chemoprophylaxis

Immunizations

  1. Hepatitis A vaccine
  2. Hepatitis B vaccine
  3. Herpes zoster vaccine
  4. Human papilloma virus vaccine
  5. Influenza vaccine
  6. Measles, mumps, and rubella vaccine
  7. Meningitis vaccine
  8. Streptococcus pneumoniae vaccine
  9. Tetanus, diphtheria, pertussis vaccine
  10. Varicella vaccine
Major Outcomes Considered

Effectiveness of preventive service

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The guideline developers used  previously published guidelines from the U. S. Preventive Services Task Force, the Advisory Committee on Immunization Practices, Medicare, and the University of Michigan Health System as the basis for the recommendations in this guideline.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials
  3. Observational trials
  4. Opinion of expert panel
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The goal of this guideline was to produce an easy-to-use list of indications for preventive services. The first step was to determine the specific services to include. The services were initially limited to two sets of widely recognized, evidence-based lists of adult clinical preventive services: those recommended by the U.S. Preventive Services Task Force (USPSTF) – levels A/strongly recommended and B/recommended – and the immunizations recommended by the Advisory Committee on Immunization Practices (ACIP). After considering the services currently recommended by these two groups, lists of adult preventive services assembled by other groups were also considered.

The Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ) supported the National Commission on Prevention Priorities in producing a 2006 update identifying priorities among effective clinical preventive services. That ranking included three services that received level B (recommended) recommendations from the USPSTF in 1996, but the recommendations for those services are currently under revision. For consistency with the available priority rankings, those preventive services and their 1996 recommendations are included. The services are vision screening (age 65+), hearing screening (age 65+), and counseling about calcium supplementation (adult women). The University of Michigan Health System (UMHS) clinical guideline on osteoporosis addresses both calcium and vitamin D supplementation for bone loss prevention in adult women, so counseling about vitamin D supplementation was also included.

The preventive services recommended by Medicare were determined to be practically relevant because a substantial proportion of adults in the U.S. have their health care covered by Medicare. Including Medicare's recommended services added glaucoma screening and prostate cancer screening and also expanded screening indications for abdominal aortic aneurysm and diabetes. Clinicians should be aware of Medicare coverage restrictions, e.g., the one-time "Welcome to Medicare" physical examination must occur within the first 12 months of enrollment in Part B.

The UMHS ambulatory care services and hospital services are accredited through the Joint Commission's Hospital Accreditation Standards. The only routine preventive service addressed in those standards concerns identifying patients who may be victims of family or intimate partner violence or abuse. This expected preventive service is also included.

Grouping Indications

The next step was to develop a practically useful list of all indications for each service. First for each service the indications were listed. In many instances the same indication was associated with several services. The list was reorganized by indication. Then the unduplicated indications were examined to determine grouping categories that made logical sense, fit typical clinical approaches to considering patient characteristics, and fit into a format that was visually easy to follow.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

  1. Generally should be performed
  2. May be reasonable to perform
  3. Generally should not be performed
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Drafts of this guideline were reviewed in clinical conferences and by distribution for comment within departments and divisions of the University of Michigan Medical School to which the content is most relevant: Family Medicine, General Medicine, Geriatric Medicine, and Obstetrics & Gynecology (Women's Health). The Executive Committee for Clinical Affairs of the University of Michigan Hospitals and Health Centers endorsed the final version.

Recommendations

Major Recommendations

Note from the University of Michigan Health System (UMHS) and the National Guideline Clearinghouse (NGC): The following guidance was current as of April 2012. Because UMHS occasionally releases minor revisions to its guidance based on new information, users may wish to consult the original guideline document External Web Site Policy for the most current version.

Note from NGC: The following key points summarize the content of the guideline. Refer to the full text for additional information, including detailed indications for preventive services and issues in performing specific services.

The strength of recommendation [I-III] and levels of evidence [A-D] are defined at the end of the "Major Recommendations" field.

Services Included

This guideline includes adult clinical preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) (levels A/strongly recommended and B/recommended) and the immunizations recommended by the Advisory Committee on Immunization Practices (ACIP). These services have been shown to offer meaningful risk reductions for subsequent events. Included are three additional services covered by Medicare and one service recommended by the Joint Commission. The services are:

Screening

  • Abdominal aortic aneurysm [IA]
  • Alcohol misuse [IC]
  • Breast cancer [IA]
  • Breast and ovarian cancer, genetic risk and BRCA mutation testing [IC]
  • Cervical cancer [IC]
  • Chlamydial infection [IA]
  • Colorectal cancer [I, fecal occult blood testing (FOBT): A; sigmoidoscopy: A; colonoscopy: B]
  • Depression [IC]
  • Diabetes mellitus, type 2 [IC]
  • Hearing [in revision, IC]
  • High blood pressure [IC]
  • Human immunodeficiency virus (HIV) [IC]
  • Lipid disorders [IA]
  • Obesity [IC]
  • Osteoporosis in postmenopausal women [IC]
  • Syphilis infection [IC]

Additional Screening Covered by Medicare

  • Glaucoma [IIA]
  • Prostate cancer [IIB]

Additional Screening Recommended by Joint Commission

  • Family and intimate partner violence [ID]

Counseling

  • Calcium and vitamin D intake [in revision, IC]
  • Diet for high risk conditions [IA]
  • Sexually transmitted infections if at risk [IA]
  • Tobacco use and tobacco–caused disease [IA]

Chemoprophylaxis

  • Aspirin for cardiovascular events [IB]
  • Breast cancer [IA]

Immunizations for

  • Hepatitis A [IA]
  • Hepatitis B [IA]
  • Herpes zoster [IA]
  • Human papilloma virus [IA]
  • Influenza [IA]
  • Measles, mumps, and rubella [IA]
  • Meningitis [IA]
  • Streptococcus pneumoniae [IA]
  • Tetanus, diphtheria, pertussis [IA]
  • Varicella [IA]

Indications for Services

Table 1 below lists indications for USPSTF recommended services and ACIP recommended immunizations grouped by gender and age, social and family history, and medical conditions and procedures. Table 2 presents indications for additional screening covered by Medicare.

Other Information

  • The relative priority of several services is presented in Table 3 in the original guideline document.
  • The USPSTF's recommendations for services that are lower priority ("C"), uncertain ("I"), and discourage ("D") are summarized in Table 4 in the original guideline document.
  • Special issues in providing specific services are noted in the text of the original guideline document.
  • Sources for the recommendations, which include more detail on specific services, are in Table 5 in the original guideline document.
  • The one-time "Welcome to Medicare" preventive visit must occur within 12 months of enrollment in Part B to be covered. After 12 months enrollment, a "wellness" visit is covered every 12 months.
  • Coding for preventive care services is described in the Appendix in the original guideline document.
  • A USPSTF tool identifies recommendations by age, gender, tobacco use, and sexual activity at http://epss.ahrq.gov/ePSS/search.jsp External Web Site Policy.
  • Working versions of questionnaires for men and women regarding the indications for specific preventive services recommended by USPSTF are available at the Clinical Care Guidelines website External Web Site Policy, which may be used along with a clinic's forms for review of systems.

Table 1. Risks and Related Preventive Services

Risks to Identify or Assess Preventive Services
General Adult Eligibility
All Adults  
All Alcohol misuse screen, e.g., CAGE [yearly]
All Depression screen, e.g., 2 question screen or PHQ 9 [yearly]
All High blood pressure screen [Q2 years; if ≥120/80 at least annually]
All Influenza vaccine – now universal* with H1N1 [yearly]
Tetanus: never or ≥10 y since vaccine Tetanus vaccine [periodic with Tdap once for some patients]
Varicella: no evidence of immunity Varicella vaccine* [1 series]
Measles or mumps: no evidence of immunity MMR vaccine* [1 or 2]
50 y to 75 y Colorectal cancer screen [periodic]
60+ y Herpes zoster* vaccine [routine]
≥65 y Hearing screen [periodic], pneumococcal vaccine [once]
Influenza vaccine: universal* or high-dose seasonal* [yearly]
Women  
(All) Calcium and vitamin D intake – counseling [periodic]
Rubella: no evidence of immunity and childbearing age MMR vaccine* [once]
High risk for breast cancer Breast cancer chemoprevention [once]
Family history of breast or ovarian cancer Refer for genetic counseling [once]
Age ≤26 y HPV vaccine [1 series]
Sexually active (also see "Lifestyle" below) Chlamydia and gonorrhea screen if risk of infection [periodic]
≥21 y (consider earlier if sexually active ) Cervical cancer screen (if cervix) [1-3 years]
If CAD risk Lipid screen [periodic]
40 y Mammogram [shared decision making] (NCCN: start annual)
50-74 y Mammogram [every 2 years] (NCCN: annual)
55-79 y if ischemic stroke benefit > GI hemorrhage risk Aspirin
50-64 y if at risk for osteoporosis (see text in the original guideline document) Bone densitometry [initial]
≥65 y Bone densitometry [initial]
≥65 y with 3 normal Pap smears, no abnormal cytology in past 10 years and normal risk Stop cervical cancer screen
Men  
Men having sex with men (see "Lifestyle" below) Hepatitis A vaccine [1 series], hepatitis B vaccine [1 series]
≤34 y if CAD risk Lipid screen [periodic]
≥35 y Lipid screen [periodic]
45-79 y if myocardial infarction benefit > GI hemorrhage risk Aspirin
65-75 y (if ever smoked) Abdominal aortic aneurysm screen by ultrasound [once**]
Social and Family History Considerations
Lifestyle  
Tobacco use Tobacco use counseling [periodic], pneumococcal vaccine [≥1]
Sexually active, multiple partner risk Screens for syphilis, HIV [all periodic], hepatitis B vaccine [1 series], intensive STI counsel
IV drug use HIV screen [periodic], hepatitis A vaccine [1 series]; hepatitis B vaccine [1 series]
Household Circumstance  
Family member with planned transplant in next 6 months, and patient varicella unexposed) Varicella vaccine* [1 series]
Household or sexual partner of persons with chronic HBV Hepatitis B vaccine [1 series]
Anticipate close contact with adoptee from country with HAV endemicity during first 60 days of adoptee's arrival in US. Hepatitis A vaccine [1 series]
Occupation  
Health care workers and health professions students who work with patients Second MMR vaccine, hepatitis B vaccine [1 series]
No immunity evidence to varicella Varicella vaccine* [1 series]
Exposure to blood/potentially infectious body fluids, e.g., institutional workers (developmentally disabled, correctional facility), public safety workers Hepatitis B vaccine [1 series]
College students Second MMR*
Also, if freshman in residential setting Add meningococcal vaccine [once]
Laboratory worker exposed to HAV or to Neisseria meningitidis Hepatitis A vaccine [1 series] or meningococcal vaccine, respectively [at least once]
Special Populations  
Residents in nursing home or long-term care facility Pneumococcal vaccine [≥1]
Exposure risk due to outbreaks of mumps or measles Second MMR vaccine*
Persons seeking HBV protection Hepatitis B vaccine [1 series]
Medical Conditions and Procedures
Chronic Cardiovascular Disease  
Obesity (body mass index ≥30 kg/m2) Intensive weight loss counseling and behavioral interventions [periodic], diabetes screen [periodic]
Hypertension (>135/80), hyperlipidemia Diabetes screen [periodic], dietary counseling [periodic]
Coronary heart disease, increased risk ASA prophylaxis [ongoing], dietary counseling [periodic]
Cardiovascular disease, diabetes mellitus Pneumococcal vaccine [≥1]
Other Chronic Disease  
Pulmonary or renal Pneumococcal vaccine [≥1]
Hemodialysis Hepatitis B vaccine [1 series, dose 40 micrograms]
Liver Pneumococcal [≥1], hepatitis A vaccine [1 series], hepatitis B vaccine [1 series]
Immunocompromised*  
Immunocompromised – includes chronic steroid use (≥20 mg prednisone daily) Pneumococcal vaccine [≥1], hepatitis B [1 series, dose 40 micrograms]
Also, if sickle cell disease, functional/anatomic asplenia, or solid organ or bone marrow transplant Add meningococcal vaccine [≥1]
Also, if HIV/AIDS Add hepatitis B vaccine [1 series], hepatitis A vaccine [1 series]
Current Sexually Transmitted Infection Intensive STI counseling
Procedures  
Cerebrospinal fluid leak or cochlear implants Pneumococcal vaccine [≥1]
Transfusions: repeated recipient of blood products Hepatitis A vaccine [1 series]; Hepatitis B vaccine [1 series]

Note: Table 1 includes the USPSTF level A and B preventive services and ACIP recommended vaccinations for adults.

*Live, attenuated vaccines (Flumist®, herpes zoster, MMR, varicella) are contraindicated if severely immunocompromised, e.g., HIV with CD4 <200 cells/µL, congenital immunodeficiencies, leukemia, lymphoma, generalized malignancy or treatment with alkylating agents, antimetabolites, radiation or chronic steroids (≥20 mg prednisone daily), <6 months after bone marrow transplant, solid organ transplant recipients. Influenza will not be effective until at least 6 months after bone marrow transplant.

Abbreviations: PHQ, Patient Health Questionnaire; Tdap, tetanus, diphtheria, and acellular pertussis; MMR, measles, mumps, rubella; CAD, coronary artery disease; GI, gastrointestinal; HPV, human papillomavirus; NCCN, National Comprehensive Cancer Network; IV, intravenous; HIV, human immunodeficiency virus; HBV, hepatitis B virus; HAV, hepatitis A virus; AIDS, acquired immune deficiency syndrome; STI, sexually transmitted infection

Table 2. Additional Preventive Screening: Covered by Medicare or Recommended by Joint Commission

Risk to Identify or Assess Preventive Services
Diabetes Glaucoma screen [periodic, ≥12 months]
Family member with glaucoma Glaucoma screen [periodic, ≥12 months]
Men age 50+ Digital rectal exam and/or PSA test [periodic, ≥12 months]
African-American and age 50+ Glaucoma screen [periodic, ≥12 months]
Hispanic-American age 65+ Glaucoma screen [periodic, ≥12 months]
Family member with abdominal aortic aneurism
or
Man age 65-75 y who has smoked >100 cigarettes
Medicare only covers abdominal aortic aneurysm screen for those at risk as part of the one-time "Welcome to Medicare" physical exam, which must occur within the first 12 months of enrolling in Part B.
All patients Family and intimate partner violence screen [periodic]

Abbreviation: PSA, prostate specific antigen

Definitions:

Strength of Recommendations

  1. Generally should be performed
  2. May be reasonable to perform
  3. Generally should not be performed

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials
  3. Observational trials
  4. Opinion of expert panel
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved rate of appropriate preventive screening and prophylaxis for adults

Potential Harms

Risks of recommended preventive services are noted in the "Issues in Performing Specific Services" section of the original guideline document.

Contraindications

Contraindications

Live, attenuated vaccines (Flumist®; herpes zoster; measles, mumps, and rubella [MMR]; varicella) are contraindicated if severely immunocompromised, e.g., human immunodeficiency virus (HIV) with CD4 <200 cells/µL, congenital immunodeficiencies, leukemia, lymphoma, generalized malignancy or treatment with alkylating agents, antimetabolites, radiation or chronic steroids (≥20 mg prednisone daily), <6 months after bone marrow transplant, solid organ transplant recipients.

Qualifying Statements

Qualifying Statements

These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Patient Resources
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
University of Michigan Health System. Adult clinical preventive care. Ann Arbor (MI): University of Michigan Health System; 2011 Dec. 20 p. [15 references]
Adaptation

This guideline includes adult preventive services recommendations from the following organizations:

  • U.S. Preventive Services Task Force
  • Advisory Committee on Immunization Practices
  • Medicare
  • University of Michigan Health Services

See the original guideline document for a list of included guidelines.

Date Released
2011 Dec
Guideline Developer(s)
University of Michigan Health System - Academic Institution
Source(s) of Funding

University of Michigan Health System

Guideline Committee

Adult Clinical Preventive Care Guideline Team

Composition of Group That Authored the Guideline

Team Leader: Michael D. Fetters, MD, MPH, MA, Family Medicine

Team Members: Elisa A. Ostafin, MD, General Medicine; Lauren B. Zoschnick, MD, Obstetrics & Gynecology; R. Van Harrison, PhD, Medical Education

Consultants: Sandro K. Cinti, MD, Infectious Diseases; Craig E. Ross, MD, Family Medicine

UMHS Guidelines Oversight Team: Connie J Standiford, MD; Grant Greenberg, MD, MA, MHSA; R Van Harrison, PhD

Financial Disclosures/Conflicts of Interest

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

Team Member/Consultant Company Relationship
Sandro K. Cinti, MD (none)  
Michael D. Fetters, MD (none)  
R. Van Harrison, PhD (none)  
Elisa A. Ostafin, MD (none)  
Craig E. Ross, MD (none)  
Lauren B. Zoschnick, MD (none)  
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the University of Michigan Health System Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

Patient Resources

The following are available:

  • Routine health care for women. Ann Arbor (MI): University of Michigan Health System; 2011. 3 p. Electronic copies: Available in Portable Document Format (PDF) from the University of Michigan Health System (UMHS) Web site External Web Site Policy.
  • Routine health care for men. Ann Arbor (MI): University of Michigan Health System; 2011. 4 p. Electronic copies: Available in PDF from the UMHS Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on March 30, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).

Disclaimer

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The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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