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Preventive Health Care Guidelines Adult/Adolescent/Pediatric – In Primary Care Setting – Clinical Practice Guideline (CPG) Target Population: Individuals from birth to geriatrics, who are average risk and asymptomatic. ACKNOWLEDGEMENT This guideline was initially developed and produced through partnership between Unity Health Insurance and Physicians Plus Insurance Corporation in 2002. Since 2005 this document has been produced as a collaborative effort between clinicians and quality improvement staff of Unity Health Insurance, Physicians Plus Insurance Corporation, University of Wisconsin Medical Foundation, the Department of Family Medicine and Group Health Cooperative. The guidelines are reviewed, revised and approved on an annual basis. This version was reviewed and approved in January 2013. 1 Chair of Preventive Health Care Guidelines Name: Sally Kraft MD Phone Number: (608) 821-4900 Email address: [email protected] CPG Contact for Content Questions or Changes: Name: Cheryl Schutte/Lee Vermeulen Phone Number: (608) 262-7537 Email address: [email protected] CPG Contact for Physicians Plus: Jody Jardine, BSN, RN, CDE Phone Number: (608) 417-4548 Email address: [email protected] Guideline Author(s), Coordinating Team Members, and Review Individuals/Bodies: See appendix A for detailed list Committee Approvals/Dates: Immunization Task Force: May 2012 Steering Committee: September 21, October 8, 13, 2012 Clinical Knowledge Management Council: December 20, 2012 Physicians Plus QUM Committee: March 27, 2013 Release Date: January 2013 2 Table of Contents Executive Summary…………………………………..4 Scope……………………………………………………6 Methodology…………………………………………...8 Evidence Rating……………………………………….9 Introduction …………………………………………..12 Recommendations …………………………………..12 Section 1 - Preventive Health Guideline for Prenatal and Postpartum Care…………………….12 Section 2 – Preventive Health Guideline for Neonatal Care...………………………………………16 Section 3 - Preventive Health Guideline for Infant-Child Care……………………………………. 17 Section 4 – Preventive Health Guideline for Adolescent Care…………………………………….. 22 Section 5 – Preventive Health Guideline for Adult Care……………………………………………..27 References for Supporting Evidence………….... 37 Benefits/Harms of Implementation…………….... 44 Implementation Strategy……………………………45 Implementation Tools/Plan…………….…………..45 Disclaimer……………………………………………..45 Appendix A…………………………………………....46 3 Executive Summary Guideline Title: Preventive Health Care Guideline Guideline Overview Preventive health services recommendations for screening, counseling and education for patients from birth to geriatrics. Practice Recommendations Health care providers need to screen, counsel and educate patients on preventive health services. Companion Documents TWEAK Questionnaire/ UW Health Alcohol Assessment http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/74_TW EAK.pdf Health Professionals Guide to Newborn Screening http://www.slh.wisc.edu/newborn/guide/ Forward Health Portal https://www.forwardhealth.wi.gov/WIPortal/Default.aspx Edinburgh Questionnaire/UW Health Guideline Diagnosing and Treating Depression http://www.testandcalc.com/etc/tests/edin.asp Childhood and Adolescent Screening Schedule http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html Badger Care Lead Screening Guidelines http://www.dhs.wisconsin.gov/lead/doc/1pgScreeningRecom.pdf 4 Center for Epidemiological Studies Depression Scale for Children-CES-DC http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc Patient Health Questionnaire- PHQ-9 http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf CRAFFT Tool http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/sc reen_CD_youth/Pages/CRAFFT.aspx Centers for Disease Control Growth Charts http://www.cdc.gov/growthcharts/ Wisconsin Essential Diabetes Mellitus Care Guidelines http://www.dhs.wisconsin.gov/diabetes/guidelines.htm Benefits and Harms Prostate-Specific Antigen-David Jarrard MD https://uconnect.wisc.edu/servlet/Satellite?cid=1119365719365&pagename=B_E XTRANET_UWHC_MANUALS%2FFlexMemberManual%2FShow_Manual_Detai l&c=FlexMemberManual Get up and Go Test http://www.aan.com/practice/guideline/uploads/273.pdf 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summ ary.Guide.pdf FRAX Osteoporosis Risk Calculation http://www.shef.ac.uk/FRAX/tool.jsp?country=9#notes Alcohol Use Disorders Identification Test-AUDIT http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf Alcohol, Smoking and Substance Involvement Screening Test-ASSIST http://www.who.int/substance_abuse/activities/assist_technicalreport_phase2_fin al.pdf SIP-AD or Severity of Dependence Scale-SDS http://www.who.int/substance_abuse/research_tools/severitydependencescale/e n/index.html United States Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf05/brcagen/brcagenrs.htm#cl inical 5 Pertinent Physicians Plus Provider Care Guidelines Alcohol Assessment and Intervention Guidelines Depression Screening Guidelines Guideline for the Treatment of Hypertension http://www.pplusic.com/providers/care-guidelines Pertinent UWHC Policies & Procedures UW Health Alcohol Assessment and Intervention Guidelines UW Health Depression Screening Guidelines UW Health Guideline for the Treatment of Hypertension UW Health Guideline for the Diagnosis and Management of Dyslipidemia UW Health Alcohol Assessment and Intervention Guideline https://uconnect.wisc.edu/servlet/Satellite?cid=1126652026690%26p agename=B_UWHC_WORKGROUPS_ADMIN%2FFlexMemberManual%2F Show_Manual_Detail%26c=FlexMemberManual Scope Adult Disease/Condition(s): Preventable diseases or conditions, such as: Tobacco or alcohol use/abuse Myocardial infarction and stroke (aspirin chemoprophylaxis) Infectious diseases, such as pneumococcal pneumonia, influenza, tetanus, diphtheria, pertussis, hepatitis B, herpes, zoster/shingles, human papillomavirus, poliomyelitis, measles, mumps, rubella, varicella Cervical cancer, colorectal cancer, breast cancer, prostate cancer Hypertension Vision and hearing impairment Chlamydia Dyslipidemia Folic acid deficiency Depression Obesity Osteoporosis and osteoporotic fractures Abdominal aortic aneurysm Children Disease/Condition(s): Preventable diseases or conditions, such as: Tobacco or alcohol use/abuse Infectious diseases, such as pneumococcal pneumonia, influenza, tetanus, diphtheria, pertussis, hepatitis B, varicella, human papillomavirus, poliomyelitis, measles, mumps, rubella, varicella, hepatitis A, rotovirus, haemophilus influenza type B, poliomyelitis Vision and hearing impairment 6 Chlamydia Dyslipidemia Folic acid deficiency Depression Obesity Sudden Infant Death Syndrome (SIDS) Injuries Dental and periodontal disease (oral health) Clinical Specialty: Family Practice Geriatrics Internal Medicine Obstetrics and Gynecology Pediatrics Preventive Medicine Intended Users: Advanced Practice Nurses Allied Health Personnel Health care providers Health Plans/Managed Care Organizations Hospitals Nurses Physician Assistants Physicians Medical Assistants Clinical Practice Guideline (CPG) objective(s): To provide a comprehensive approach to the provision of preventive services, counseling, education and disease screening for average risk individuals from birth through geriatrics. To assist in the prioritization of screening, maneuvers, tests and counseling opportunities. To increase the rate of patients who are up to date with preventive services. To provide guidelines for decision support tools in Health Link such as Health Maintenance and Best Practice Alerts. 7 Target Population: Individuals from birth to geriatrics who are average risk and asymptomatic. Please Note: there are occasional exceptions to this for high risk populations where noted. This guideline is not intended to diagnose or treat any condition. Once a health issue or condition has been uncovered, other guidelines will take precedence during any further diagnosis and management. Interventions and Practices Considered: Prevention/Risk Assessment/Screening/Counseling Patient centered, team based approach and shared decision making. Using nearly every patient contact to identify and address preventive service needs. Screening Screening including: Neonatal screening Chlamydia screening Colorectal, breast and cervical cancer screening Vision and hearing impairment Obesity and lipid screening Tobacco and alcohol screening Hypertension Depression and mental health screening Immunization screening Counseling Breast feeding Injury prevention Sudden infant death syndrome (SIDS) Oral health Domestic violence Major Outcomes Considered Effectiveness of screening tests Effectiveness of counseling and education Effectiveness of immunization and chemoprophylaxis Predictive value of screening tests Methodology Description of Methods Used to Collect/Select the Evidence: The work group reviewed previous guideline recommendations and came to consensus on the content to be included in the guideline. Searches of electronic data bases as well as hand searches were conducted to update and verify content. Randomized, controlled trials and meta-analysis/systemic reviews and guidelines were included. 8 Methods Used to Assess the Quality and Strength of the Evidence: This clinical practice guideline will be using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) as defined by U.S. Preventive Services Task Force (USPSTF) which assigns one of five letter grades to each of its recommendations (A, B, C, D, or I) (Tables 1 and 2). Table 1: Rating Scheme for the Strength of the Evidence: Grade Definition Suggestions for Practice A Recommend the service. There is high certainty that the net benefit is substantial. Offer or provide this service. B Recommend 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 Note: The following statement is Offer or provide this service only if other considerations support the offering or undergoing revision. Clinicians may provide this providing the service in an individual patient. 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 this service. D Recommend against the service. Discourage the use of this service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I Statement Conclude 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. Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. 9 Table 2: Levels of Certainty Regarding Net Benefit Level of Certainty* Description High The available evidence usually includes consistent results from welldesigned, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in the chain of evidence. Findings not generalizable to routine primary care practice. Lack of information on important health outcomes. More information may allow estimation of effects on health outcomes. * The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service. Description of the Methods Used to Analyze the Evidence: Weighting according to the rating scheme given. Description of Methods Used to Formulate the Recommendations: Review of published studies, meta-analyses and expert opinions. Cost Analysis: No cost analysis. 10 Description of Method of Guideline Validation: Specialty workgroups made up of specialists and primary care physicians reviewed the evidence of controversial topics and made a recommendation based on evidence or formed a consensus guideline which was reviewed by the Steering Committee. The expert contributors made up of physicians and staff in a specialty area reviews the recommendations by specialty workgroups and the entire Preventive Health Care Guideline for content. The Steering Committee is made up of primary care physicians, ObGynecologists, representatives from HMO groups (Physician, Plus, Group Health Cooperative and Unity), Health link analyst and members from the quality department. They reviewed the recommendations from the specialty workgroups and the expert contributors. Council for Clinical Knowledge Management will review and give final approval for the Preventive Health Care Guidelines. See flow diagram below of the process. 11 Preventive Health Care Guidelines Specialty workgroups, expert contributors and the steering committee follow the CPG guiding principles as well as those listed below: Members will serve as a representative of their discipline/department. They will inform colleagues of the goals and report on feedback from colleagues. They will represent concerns and provide suggestions for resolution. Recommendations are based on the highest levels of evidence Recognize there maybe conflict or controversy Refer to levels of evidence Create a consensus statement for the Preventive Health Care Guidelines with input from specialty experts. Steering Committee can make recommendations for and against for building tools in Health Link, based on the evidence Committee will update the guidelines as needed if new evidence comes forward or if there is concern that arises between the 2 year periodic reviews. INTRODUCTION This guideline contains recommendations designed to assist clinicians in delivering and supporting preventive health care services. RECOMMENDATIONS Major Recommendations: Section 1. Preventive Health Guideline for Prenatal and Postpartum Care FREQUENCY OF PRENATAL VISITS GESTATIONAL AGE FREQUENCY OF VISITS 4 - 32 weeks Every 4 weeks 32 - 36 weeks Every 2 weeks 37+ weeks Every week 12 PRENATAL / POSTPARTUM PREVENTIVE CARE TIMELINE SCREENINGS PRE-PREGNANCY • Screen for HIV. Screen for depression. 5 Screen for alcohol use.6 TREATMENT STANDARDS Daily prenatal vitamin containing 0.4 – 0.8 mg folic acid for women planning pregnancy.1 Begin at least 1 month prior to conception and continue during pregnancy. FIRST PRENATAL VISIT • Screen for gonorrhea and chlamydia, syphilis, and HIV (if not done preconceptually) • Offer screen for cystic fibrosis to appropriate ethnic groups. • Screen for blood type and Indirect Coombs antibody testing. (Grade A Recommendation, USPSTF). • Pap test. • AfricanAmerican women should be tested for sickle cell disease. • Recommend offering carrier screening for hemglobinopathies to women of southeast Asian, African or Mediterranean descent. • Screen for iron deficiency. DURING PREGNANCY • Urine testing at 12 – 16 weeks with urinalysis to include leukocyte esterase and urine culture to screen for asymptomatic bacteriuria. • Screen for Group B Streptococcus late in pregnancy3 (3537 weeks). • Screen for indirect Coombs antibody testing if not previously done. • Screen for gestational diabetes at 26-30 weeks or sooner if risk factors.4 Screen for depression.5 Screen for alcohol use.6 Provide Rh (D) immune globulin to all Rh negative women at 28 weeks. AFTER PREGNANCY Screen for postpartum depression.5 Screen for alcohol use.6 • Administer Rh (D) immune globulin to un-sensitized postpartum Rh negative women within 72 hours of birth, if fetus is Rh positive or unknown. • Check-up within 4 – 6 weeks after delivery. 13 VACCINATIONS PRE-PREGNANCY • Screen for rubella or vaccination if no previous immunity at least 4 weeks prior to becoming pregnant. • Screen for varicella or vaccination if no previous immunity 8 weeks prior to becoming pregnant. • Screen for family members and close contacts for Tdap and administer.7 FIRST PRENATAL VISIT • Screen for rubella (if not done preconceptually). • Screen for hepatitis B2 DURING PREGNANCY • During flu season offer vaccine to all women regardless of trimester. Pregnant women should only receive inactivated flu vaccine. •Give Tdap between 27-36 weeks. Screen family members and close contacts for Tdap and administer if not given previously.7 AFTER PREGNANCY • Varicella vaccination if no previous immunity. • Rubella vaccination if no previous vaccination. • Screen family members and close contacts for Tdap and administer if not given previously.7 1. Folic Acid – Women with history of a prior child with a neural tube defect or family history of neural tube defect should be offered a higher dose of 4 mg per day of folic acid. (Grade A Recommendation, USPSTF)1 All prescription prenatal vitamins have 1 mg folic acid. All OTC vitamins have 0.4 mg folic acid. 2. Hepatitis B – Mothers who are at high risk of contracting hepatitis B and who are HBsAg negative may receive a hepatitis B immunization series anytime during pregnancy. Such mothers should be retested for hepatitis B prior to delivery. (Grade A Recommendation, AAFP)2 3. Group B Strep – Risk-based treatment is only appropriate if screening has not been done or culture results are not known.3 4. Gestational DiabetesScreen sooner if macrosomia, maternal obesity or history of gestational diabetes. 5. Depression – Screen for prenatal depression and assess medications for depression. Screen for depression during pregnancy and postpartum. Please refer to Physicians Plus Depression Guidelines at: http://www.pplusic.com listed under Clinical Practice Guidelines. 14 6. Alcohol – Screen and address alcohol use both prior to and during pregnancy. (Grade B Recommendation, USPSTF).4 Assess alcohol use using the quantityfrequency questions. If any alcohol use exists, use the TWEAK questionnaire and advise to abstain from alcohol. Assist as appropriate; if necessary, arrange treatment or follow-up. For additional information on alcohol screening and the TWEAK questions, refer to the Physicians Plus Alcohol Assessment and Intervention Guideline at: http://www.pplusic.com/ listed under Clinical Practice Guidelines. 7. Tdap – Administer a dose of Tdap during each pregnancy in the third trimester, between 27 and 36 weeks gestation, irrespective of the patient’s prior history of receiving Tdap. If Tdap is not administered during pregnancy, Tdap should be administered immediately postpartum.5,6,7,8 8. Hemoglobinopathies – Recommend offering carrier screening for hemoglobinopathies to women of Southeast Asian, African or Mediterranean descent.9 PRENATAL HEALTH EDUCATION AND COUNSELING 1. Discuss diet, substance abuse, current or history of depression or anxiety, domestic violence, safety and environment. 2. Reduce or stop tobacco use for those who use, and discuss availability of nicotine replacement therapies and medications as an adjunct to counseling. (Grade A Recommendation, USPSTF)10 3. Discuss benefits of breastfeeding during prenatal visits. (Grade B Recommendation, USPSTF)11 4. Offer amniocentesis or chorionic villi sampling for women 35 years or older. 5. Offer genetic screening in first or second trimester. Offer quad marker screen to detect chromosome (Down syndrome), brain and spinal cord abnormalities. Offer a choice of quad screen for Down syndrome or first trimester screen. If first trimester screen is elected for screening for Down Syndrome, need to offer AFP screening for neural tube defect in the second trimester. If quad screen is elected for Down’s screening, it will automatically screen for neural tube defect. 6. Recommend that all close family contacts and care givers of infants be up to date with immunizations, especially Tdap.7 7. Recommend routine screening for iron deficiency anemia in asymptomatic pregnant women. (Grade B recommendation, AAFP)12 15 Section 2. Preventive Health Guideline for Neonatal Care Car Administration Intramuscular injection of vitamin K within 1 hour of birth to prevent hemolytic disease of the newborn. Ophthalmic antibiotic topically to eyes within 1 hour of birth. Hepatitis B vaccine to infants prior to discharge from the hospital. Hepatitis B vaccine within 12 hours of birth to infants born to HBsAg positive mothers or to whom mother’s status is unknown. Hepatitis B Immune Globulin (HBIG) within 12 hours of birth to all infants born to HBsAg positive mothers and to infants under 2000 grams birth weight born to previously untested mothers whose hepatitis B status is unlikely to be determined within 12 hours of birth. HBIG can be deferred up to 7 days in infants over 2000 grams birth weight born to previously untested mothers while awaiting the mother's HBsAg test results. Vitamin D within the first few days of life. Recommend all exclusively breast-fed or formula fed babies receiving less than 1000 mL of formula per day within first few days of life begin to receive vitamin D supplement 400 IU. Vitamin supplementation is also recommended for breastfed babies who are receiving formula supplementation. Screening Hearing loss using current medical techniques. (Grade B Recommendation, USPSTF)13 Congenital heart disease using pulse oximeter within 24-48 hours of birth. The State of Wisconsin statutes for newborn screening.14 Screening is currently conducted for 48 disorders and diseases. The complete list is available at: http://www.slh.wisc.edu/newborn/guide Health Professionals Guide to Newborn Screening: Table of Contents. Testing should be conducted after 24 hours of life. Infants should be tested before discharge from the neonatal nursery, and if discharged before 24 hours of age, should be re-tested by 2 weeks of age. Premature infants and those with illnesses optimally should be tested at or near 7 days of age, but in all cases before discharge from the newborn nursery. Education Sudden Infant Death Syndrome (SIDS) prevention. Endorse the safe to sleep program. Benefits of breastfeeding. Provide support and follow-up. 16 Section 3. Preventive Health Guideline for Infant-Child Care Car INFANT-CHILD CARE TIMELINE BIRTH TO 1 MO 2 MO 4 MO 6 MO 9 MO 12 MO 15 MO 18 MO 24 MO Once Once Once Once Once Once Once Once and 1 Care Plus eligible At least years Once Once Once (24-30 Once months) AUTISM SCREEN (M-CHAT)1 Once Once BP SCREEN BLOOD LEAD LEVEL SCREEN (FOR THOSE AT RISK)2 Once Once if at if at risk risk ANEMIA SCREENS BMI6 every 1-2 Once DEVELOPMENTAL SCREENING (ASQ)1 VISION SCREEN5 Annually children month HEARING SCREEN4 7-10 YR Badger hours of discharge 3-6 YR Only for Within 48 WELL CHILD VISIT1 30 MO2 If at risk If at risk Once If at risk Once if at risk and not previously checked Once Once Once Once Once Once At each clinic visit clinic visit Once if at risk and not previously checked If at risk Birth Once At each Once Once Once Once Once Annual screen at ages 4-6 Annual screen at ages 8 and 10 Annually Risk assessment annually and vision screen at 8,10, Annually Annually Universal screening LIPIDS7 If at risk at 9-10 yrs If at risk If at risk with nonfasting cholesterol and HDL 17 If at risk TUBERCULOSIS8 SCREEN FOR POSTPARTUM DEPRESSION9 1. Once If at risk If at risk If at risk If at risk If at If at risk risk If at risk If at risk Once Health Check All infants discharged on the first or second postpartum day need to be seen within 48 hours of discharge. Breastfeeding infants need to be seen within 48 hours of discharge. This is a State recommendation for children who are Medicaid or HealthCheck eligible. For the Medical Assistance (BadgerCare Plus) Health Check go to: www.forwardhealth.wi.gov/WIPortal/Default.aspx Developmental surveillance is recommended at all Well Child visits. Universal developmental screening with a standardized validated developmental screening tool (such as the Ages and Stages Questionnaire) is recommended for all children at 9, 18, and 24-30 months of age, as well as targeted screening at any age when developmental concerns are identified by developmental surveillance. 15 Autism screening with M-CHAT is recommended at 18 and 24 months of age, and any other time when parents raise a concern about a possible Autism Spectrum Disorder (ASD).16 2. Blood Lead Screening – Perform lead test on children at 12 and 24 months if the answer to any of the following is ‘yes’ or ‘don’t know’: QUESTION TEST IF THE ANSWER IS 1. Does the child live in or visit a building constructed before 1950? Has the child in the past? Yes / Don't know 2. Does the child live in or visit a building constructed before 1978 with recent or ongoing renovation? Has the child in the past? Yes / Don't know 3. Does the child have a brother, sister or playmates that has or has had lead poisoning? Yes / Don't know 4. Is the child eligible for Medicaid, Health Check or WIC? Yes / Don't know For MA (Badge Care Plus) Lead Screening Guidelines go to http://dhfs.wisconsin.gov/lead/doc/1pgScreeningRecom.pdf 18 3. Anemia Screening CBC w/o diff at one year of age. At ages 9-12 months and at ages 15-18 months, assess infants and young children for risk factors for anemia. Screen the following children: Preterm or low-birth weight infants Infants fed a diet of non-iron-fortified infant formula for greater than 2 months Infants introduced to cow's milk before age 12 months Breast-fed infants who do not consume a diet adequate in iron after age 6 months (i.e., who receive insufficient iron from supplementary foods) Children who consume greater than 24 oz daily of cow's milk Children who have special health-care needs (e.g., children who use medications that interfere with iron absorption and children who have chronic infection, inflammatory disorders, restricted diets, or extensive blood loss from a wound, an accident, or surgery) Recommend routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia. 4. Hearing Screening Recommend annual screening 4-6 years of age and 8 and 10 years of age with 2-3 pure tones. Test each ear at 20dB with four frequencies (500, 1000, 2000 and 4000 Hz.)17 5. Vision Screening – Children should have an assessment for eye problems. These should be age-appropriate evaluations; visual acuity measurement is recommended for all children starting at 3 years of age. (Grade B Recommendation, USPSTF)18 All children who are found to have an ocular abnormality and who fail valid vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients. 6. Obesity/BMI – For CDC clinical growth charts with BMI go to:http://www.cdc.gov/growthcharts. Screen individuals age 2-17 for obesity. As appropriate, provide counseling for persons 2 years and older for nutrition and physical activity. Document BMI. Provide counseling for individuals who are greater than or equal to 85th percentile. Offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. (Grade B Recommendation, USPSTF)19 19 7. Lipids Screening – Universal screening at 9-11 years of age with non fasting cholesterol and HDL. Screen once with fasting lipid profile for at risk patients after 2 years of age. Risk factors: patients with a positive family history of dyslipidemia or premature (55 years of age for men and 65 years of age for women) CVD, for whom family history is not known or those with other CVD risk factors, such as overweight (BMI 85th percentile), obesity (BMI 95th percentile), hypertension (blood pressure 95th percentile), cigarette smoking, or diabetes mellitus. 8. Tuberculosis - 20 Screen for risk factors and test if at risk. Tuberculin skin test (TST) or interferon gamma release assays (IGRA) should be done on anyone at risk with positive screening questionnaire. IGRA recommended as screening test after 5 years old. In children 2 to 4 years of age there is limited data about the usefulness of IGRAs in determining TB infection but IGRA can be performed if disease is suspected. TST should not be done before 3 months of age. Risk factors include: Contacts with people with confirmed or suspected TB, radiographic or clinical findings suggesting TB. Contacts with people immigrating from countries with endemic infection (Asia, Middle East, Africa, Latin America, countries of the former Soviet Union, including international adoptees). Children with travel histories to countries with endemic infection and substantial contact with indigenous people. Children with HIV infection and other medical conditions such as diabetes, chronic renal failure, malnutrition, congenital or acquired immunodeficiency and children receiving TNF should have annual TST or IGRA. 9. Postpartum Depression – Recommend using Edinburgh Postnatal Depression Scale (EPDS) at 1 and 4 months. If there is a personal or family history of depression, anxiety or other mood disorders or psychosocial risk factors such as social isolation/lack of social support, domestic violence and/or substance abuse then follow up screening at subsequent visits maybe warranted. Please refer to the Physicians Plus Guideline Diagnosing and Treating Depression in Adults in Primary Care http://www.pplusic.com listed under Clinical Practice Guidelines. 20 INFANT-CHILD IMMUNIZATIONS Please refer to the Recommended Childhood and Adolescent Immunization Schedule approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians. The Schedule is provided in its entirety at the Centers for Disease Control website at http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html for infants and children.21 Families choosing not to immunize or who do not follow the recommended immunization schedule need to sign a vaccine refusal form. INFANT-CHILD HEALTH EDUCATION AND COUNSELING Injury Prevention Water safety: bathtub and pool supervision at all times and a barrier or fence. Suggest CPR training for pool owners, parents, and care takers. Falls: window guards in high-risk buildings. Use of gates. Never leave infant unattended on changing table. Firearm safety: firearms properly stored – locked up and not loaded – at all times Bicycling: use of approved helmets ATVs and Motorcycles: Children under age 16 should not operate offroad motorized vehicles (i.e. ATV, personal watercraft, snowmobiles or mini bikes) Poison Prevention- child-proof containers kept out of reach and limit number of tablets per package. Keep National Poison Control Number readily available. Burn Prevention- smoking cessation, flame-retardant clothing, hot water heaters set to <120 degrees Fahrenheit, and properly installed and tested smoke detectors and carbon monoxide detectors. Motor Vehicle Safety-Advocate use of infant and rear facing child car seats until 2 years of age, booster seats and seat belt until child is 4’9”. Recommend against children 12 years of age and under riding in the front seat. Encourage sun avoidance or use of protective clothing while in the sun. (Grade B Recommendation, USPSTF) .22 Use SPF 15 or greater when in the sun. Education Promote a balanced diet high in fruits, vegetables, grains and fiber and encourage adequate calcium intake (4 or more servings per day). After age two recommend a diet low in saturated fat and cholesterol. Promote an active lifestyle with regular exercise. Limit screen time to no more than two hours of quality programming per day for children two years and older. No screen time for children less than two years of age. (Screen time includes television, video games and computers) 21 Provide oral hygiene education at each well child visit. Refer to dental home by age 2-3. Counsel parents not to smoke. Discuss availability of nicotine replacement therapies and medications as an adjunct to counseling. Counsel on risks of second and third hand smoke. Section 4. Preventive Health Guideline for Adolescent Care ADOLESCENT CARE TIMELINE 11 12 13 14 15 16 17 Annually* Annually* Annually* Annually* Annually* Annually* Annually* BP SCREENING At each clinic At each visit clinic visit At each clinic visit At each clinic visit At each clinic visit At each clinic visit At each clinic visit Based on risk Based on risk factors factors WELL CHILD VISIT *BASED ON PPLUS RECOMMENDATIONS VISION SCREENING CHLAMYDIA, GONORRHEA, HIV SCREEN2 Once Based on risk factors Based on risk factors Once Based on risk factors Based on Based on risk factors risk factors ALCOHOL TOBACCO AND DRUG USE SCREEN3 Annually Annually Annually Annually Annually Annually Annually BMI4 Annually Annually Annually Annually Annually Annually Annually non-fasting cholesterol 5 LIPIDS and HDL if Universal not Screening previously tested HEARING6 TUBERCULOSIS7 DEPRESSION SCREENING9 For those at For those For those at For those at For those at For those at For those at risk risk at risk risk risk risk risk If at risk If at risk If at risk If at risk If at risk If at risk If at risk Once Once Once Once Once Once 22 1. Health Check Screen adolescents for hypertension, eating disorders, sexual activity, abuse, and school performance at each health visit. Screen children 11-18 years of age for mental health disorders. Ensure systems are in place for accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal) and follow-up. Use appropriate screening resources. Address readiness for transition to adult care. 2. Chlamydia, Gonorrhea Infection and HIV – Screen all sexually active females at least annually (Grade A Recommendation, USPSTF)23 and at risk males. Risk factors include being sexually active. Screen for human immunodeficiency virus (HIV) for all adolescents at increased risk for HIV infection. (Grade A Recommendation, USPSTF)24. Consider screening sexually active young men and adolescent males in clinical settings associated with high chlamydia prevalence (e.g., adolescent clinics, correctional facilities, and STD clinics.) Annual screening for men who have sex with men. Recommend screening all males whose partners have chlamydia, those who attend STD clinics or clinics in communities where prevalence rates are high. Males younger than 30 years of age who are in the military and those in jail should be screened; as should males in juvenile justice facilities or Job Corps. CDC recommends that everyone between the ages of 13 and 64 get tested for HIV at least once as part of routine health care. Please note that this recommendation differs from current USPSTF recommendations However USPSTF issued draft recommendations 11/20/12 that all individuals ages 15-65 should have at least one screening for HIV. (Grade A Recommendation, USPSTF in draft).24 An HIV test is recommended once a year for people at increased risk—such as gay and bisexual men, injection drug users, or people with multiple sex partners. Sexually active gay and bisexual men may benefit from more frequent testing (e.g., every 3 to 6 months). 3. Alcohol, Tobacco and Drug Use – Screen adolescents using the CRAFFT screening tool: C-Have you ever ridden in a car driven by someone (including yourself) that was “high” or had been using alcohol or drugs? R-Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? A-Do you ever use alcohol or drugs while you are by yourself, alone? F-Do you ever forget things you did while using alcohol or drugs? 23 F-Do your family or friends ever tell you that you should cut down on your drinking or drug use? T-Have you ever gotten into trouble while you were using alcohol or drugs? Two or more yes answers suggest a significant problem, abuse, or dependence. If positive for use, have brief intervention using motivational interviewing techniques. Refer to specialist for treatment of dependence if indicated. Screen for tobacco use annually. 4. Obesity/BMI – For CDC clinical growth charts with BMI go to: http://www.cdc.gov/growthcharts . As appropriate, provide counseling for persons 11-17 years of age for nutrition. For persons eleven years and older, counsel for nutrition and physical activity as appropriate. Document BMI. Provide counseling for individuals who are greater than or equal to 85th percentile. Refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. (Grade B Recommendation, USPSTF)25 5. Lipid Screening – 28-37 Screen at 11 if not done at 9-10 years of age. Screen with non-fasting cholesterol and HDL. Universal screening once from 17-21 years of age. Screen with fasting lipid profile for at risk patients. Risk factors: patients with a positive family history of dyslipidemia or premature (55 years of age for men and 65 years of age for women) CVD, for whom family history is not known or those with other CVD risk factors, such as overweight (BMI 85th percentile), obesity (BMI 95th percentile), hypertension (blood pressure 95th percentile), cigarette smoking, or diabetes mellitus. 6. Hearing ScreeningPerform risk assessment with appropriate action if positive. noise exposure. 7. Discuss loud Tuberculosis- 20 Screen for risk factors and test if at risk. Tuberculin skin test (TST) or interferon gamma release assays (IGRA) should be done on anyone at risk with positive screening questionnaire. IGRA recommended as screening test after 5 years old. In children 2-4 years of age there is limited data about the usefulness of IGRAs in determining TB infection but IGRA can be performed if disease is suspected. TST should not be done before 3 months of age. Risk factors include: 24 8. Contacts with people with confirmed or suspected TB, radiographic or clinical findings suggesting TB. Contacts with people immigrating from countries with endemic infection (Asia, Middle East, Africa, Latin America, countries of the former Soviet Union, including international adoptees). Children with travel histories to countries with endemic infection and substantial contact with indigenous people. Children with HIV infection and other medical conditions such as diabetes, chronic renal failure, malnutrition, congenital or acquired immunodeficiency and children receiving TNF should have annual TST or IGRA. DepressionScreen for depression in adolescents aged 12-18 years for major depressive disorder when staff assisted systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow up. (Grade B Recommendation, USPSTF) 26 ADOLESCENT IMMUNIZATIONS Please refer to the Recommended Childhood and Adolescent Immunization Schedule approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians. The Schedule is provided in its entirety at the Centers for Disease Control website at http://www.cdc.gov/vaccines/schedules/hcp/childadolescent.html for children and adolescents.21 Families choosing not to immunize or who do not follow the recommended immunization schedule need to sign a vaccine refusal form. ADOLESCENT HEALTH EDUCATION AND COUNSELING Injury Prevention Motor vehicle safety: Advocate use of seat belt. No texting while driving. Burn Prevention: smoking cessation, flame-retardant clothing, hot water heaters set to <120 degrees Fahrenheit, and properly installed and tested smoke detectors. Water safety: pool supervision at all times and a barrier or fence. Suggest CPR training for pool owners, parents, and caretakers. Use personal flotation devices with watercraft sports. Firearm safety: firearms properly stored – locked up and not loaded – at all times Promote use of approved helmets for bicycling, snowboarding, skiing, motorcycling. 25 ATVs and Motorcycles: The American Academy of Pediatrics specific recommendation is that children under 16 should not operate off-road motorized vehicles (i.e. ATV, personal watercraft, snowmobiles or mini bikes). Encourage sun avoidance or use of protective clothing while in the sun. (Grade B Recommendation, USPSTF)22 Use SPF 15 or greater when in the sun. Education Suggest regular dental visits, counsel on oral hygiene and address fluoride supplement for those with inadequate fluoride Promote a balanced diet high in fruits, vegetables, grains and fiber and encourage adequate calcium intake (4 or more servings per day). Recommend a diet low in saturated fat and cholesterol. Promote an active lifestyle with regular exercise. Limit screen time to no more than 2 hours daily of quality programming for children 2 years and older. (Screen time includes television, video games and computers.) Advise tobacco users to stop; counsel non-smokers to never start. Counsel parents not to smoke. Discuss availability of nicotine replacement therapies and medications as an adjunct to counseling. Discuss the hazards of alcohol and other substance use. Strongly advise against the use of alcohol, tobacco and other illicit drugs by youth. Avoidance of contaminated injection equipment to prevent HIV. Encourage sexual abstinence or monogamous sexual relationships, use of condoms, and birth control. Counsel on STI and pregnancy prevention. Recommend behavioral counseling to prevent STIs for all sexually active adolescents at increased risk of STIs. (Grade B Recommendation, USPSTF)23 26 Section 5. Preventive Health Guideline for Adult Care ADULT PREVENTIVE CARE TIMELINE MEN AND WOMEN 18-29 Blood Pressure1 Lipid Screening2 30-39 40-49 50-64 65-69 Every 1-2 years beginning at age 18 Universal screening once between ages 17-21, then every 5 years. lo, High Sensitivity Fecal Occult Blood Test annually or Sigmoidoscopy every 5 years or CT Colonography (Virtual) every 5 years* or Optical Colonoscopy every 10 years 50-75 years of age Colorectal Screening 3 *Requires prior authorization Screening for Pre diabetes and Diabetes4 Screen all people beginning at age 45. If normal and person has no risk factors, retest in 3 years. Tobacco, Alcohol and Depression5 All adults BMI6 All adults Not recommended at this time. Hepatitis C Virus Screening7 HIV Screening8 Screen all adults at increased risk. Begin screening at age 65. Fall Screening9 MEN ONLY Abdominal Aortic Aneurysm10 18-29 30-39 40-49 50-69 70 AND OLDER Once for 65 yrs-75 men who have ever smoked. 27 Counsel men at least once regarding screening for prostate cancer. Prostate Screening11 Chlamydia and Gonorrhea12 WOMEN ONLY Not recommend routine screening. 18-29 30-39 40-49 65-69 Chlamydia and Gonorrhea Screening13 Annually for all sexually active women age 24 and younger and others at increased risk Cervical Cancer Screening14 Begin screening low risk Screen low risk populations every 3 populations years with cytology only or 5 years with at age 21, cotesting (cytology and high risk HPV). every 3 years with cytology. Mammogram (with or without clinical breast exam)15 Routine screening mammography every 1-2 years for women aged 50-74. A baseline screening mammogram should be obtained in average risk 4049 year old women, preferably at age 40. Recommend additional screening mammography for women age 40-49 every 1-2 years based on a discussion of the risks and benefits of mammography in this age group. Recommend screening every 1-2 years for women age 75-85 based on a discussion of the risks and benefits of screening mammography in this age group. Screen for Osteoporosis16 Screen for Violence17 1. 50-64 65 and older Screen women of childbearing age for intimate partner violence. Hypertension – Refer to the Physicians Plus Guideline for the Treatment of Hypertension for detailed screening and treatment recommendations at http://www.pplusic.com listed under Clinical Practice Guidelines. (Grade A Recommendation, USPSTF)2 28 2. Dyslipidemia – 28-37 Universally screen once for adults age 17-21. (Grade B Recommendation, National Heart Lung and Blood Institute) Test with a fasting lipid panel (total cholesterol, LDL, HDL and Triglycerides) or non-fasting total cholesterol and HDL once every 5 years. Based on the judgment of the provider, if LDL and TG levels are low and overall cardiovascular risk is low, subsequent screening maybe delayed and considered every 10 years. If non-fasting study is performed and total cholesterol is >200mg/dl or HDL is <40 mg/dl, follow up with lipoprotein profile for LDL management. May stop screening at age 75. 3. Colorectal Screening Acceptable screening includes fecal occult blood testing, sigmoidoscopy or colonoscopy. (Grade A Recommendation, USPSTF)35 Traditional also known as endoscopic or optical colonoscopy is recommended every 10 years. Virtual is recommended every 5 years and Physicians Plus requires prior authorization for coverage. Follow-up is based on test findings. Recommend screening men and women age 50-75 years for colorectal cancer. (Grade A Recommendation, USPSTF)38 4. Diabetes – Physicians Plus refers to the American Diabetes Association (ADA) Standards of Medical Care in Diabetes for specific screening, diagnosis and treatment recommendations for patients with diabetes.39 This guideline is available at http://www.pplusic.com listed under Clinical Practice Guidelines. The UW Health Preventative Health Care Guideline refers to the Wisconsin Essential Diabetes Mellitus Care Guidelines for specific screening, diagnosis and treatment recommendations for patients with diabetes.39 They are available through U-Connect at https://uconnect.wisc.edu listed under Clinical Practice Guidelines. Screen all people with BMI less than 25 beginning at age 45. If normal and person has no risk factors, retest in 3 years. If BMI is greater than or equal to 25 with no or at least one additional risk factor, begin screening sooner and perform annually. Screening can be done with a fasting plasma glucose or A1C. USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (Grade B Recommendation, USPSTF)40 29 5. Tobacco, Alcohol and Depression Recommend that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (Grade A Recommendation, USPSTF)41 Provide alcohol-screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women in primary care settings. (Grade B Recommendation, USPSTF)42 Screen adults for depression when staff assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow up. No specific interval was recommended. (Grade B Recommendation, USPSTF)43 Please refer to the Physicians Plus Guideline Diagnosing and Treating Depression in Adults in Primary Care listed under Clinical Practice Guidelines at http://www.pplusic.com 6. Obesity/BMI – Screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. (Grade B Recommendation, USPSTF)44 7. Chronic Hepatitis C Virus (HCV) Infection – CDC recommends adults born between the years 1945-1965 should receive one time testing without prior ascertainment of risk of infection. Any patient identified with HCV infection should receive a brief alcohol screening and intervention if indicated, followed by referral to specialty care for HCV infection and related conditions. 45 However, USPSTF recommends against routine screening for hepatitis C virus (HCV) infection in asymptomatic adults who are not at increased risk for infection. (Grade D Recommendation, USPSTF, Update in Progress)46 8. HIV Screening Recommend clinicians screen for human immunodeficiency virus (HIV) for all adults at increased risk for HIV infection. (Grade A Recommendation, USPSTF) 47 9. Falls Risk Screening Screen all older individuals if they have fallen (in the past year). The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program. 30 (Grade A Recommendation, AGS)48 The components most commonly included in efficacious interventions were: a) Adaptation or modification of home environment (Grade A Recommendation, AGS)48 b) Withdrawal or minimization of psychoactive medications (Grade B Recommendation, AGS)48 c) Exercise, particularly balance, strength, and gait training (Grade A Recommendation, AGS)48 Primary care clinicians can consider the following factors to identify older adults at increased risk for falls: a history of falls, a history of mobility problems, and poor performance on the timed Get-Up-and-Go test (observing the time it takes a person to rise from an armchair, walk 3 meters (10 feet), turn, walk back, and sit down again, <10 seconds). (USPSTF and American Geriatrics Society/ British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons) http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/falls prevrs.pdf Recommend exercise or physical therapy and vitamin D supplementation to prevent falls in community dwelling adults aged 65 years and older who are at increased risk for falls. (Grade B Recommendation, USPSTF) 49 http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm 10. Abdominal Aortic Aneurysm Recommend one time screening by ultrasonography in men aged 65-75 who have ever smoked. (Grade B Recommendation, USPSTF)50 11. 51-57 Prostate Cancer Screening – Counsel men age 40-69, at least once regarding prostate cancer screening. Discuss the potential benefits and harms of prostate specific antigen (PSA) testing and treatment and consider patient risk factors. Risk factors for increased prostate cancer mortality include African American ancestry or having a first degree relative (father, brother or son), diagnosed with prostate cancer at 65 years of age or younger. Do not recommend screening for men 70 years and older. The USPSTF currently does not recommend PSA screening for prostate cancer. (Grade D Recommendation, USPSTF) The American Cancer Society and the American Urological Association recommend discussion of the potential benefits and harms of PSA testing and deciding with the patient whether to do PSA testing. 31 12. Chlamydia and Gonorrhea Screening for MenAnnual screening for men who have sex with men. Recommend screening all males whose partners have Chlamydia; those who attend sexually transmitted infection clinics or clinics in communities were prevalence rates are high. Males younger than 30 years of age who are in the military and those in jail, males in juvenile justice facilities or Job Corps or anyone who requests testing annually should be screened. Although evidence is insufficient to recommend routine screening for C. trachomatis in sexually active young men because of several factors (including feasibility, efficacy, and cost-effectiveness) , the screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STD clinics) CDC 2010 STD Guideline.58 13. Chlamydia and Gonorrhea Screening for Women At least annually for all sexually active woman age 24 and younger and for older non pregnant women who are at increased risk for infection. (Grade A Recommendation, USPSTF)59 Risk factors include having more than one sexual partner, having had a sexually transmitted infection in the past, or not using condoms consistently or correctly. Recommends screening for human immunodeficiency virus (HIV) all adults at increased risk for HIV infection. 14. Cervical Cancer Screening – 60-66 Screen women age 21-29 with cytology alone every 3 years. High risk patients may require more frequent screening. High risk patients include: HIV positive, immunocompromised (including transplant patients), have a history of DES exposure or prior history of CIN 2, 3 or cervical cancer. (Grade A Recommendation, USPSTF) Screen women age 30-65 with a combination of cytology and high risk HPV every 5 years OR screen with cytology only every 3 years. (Grade A Recommendation, USPSTF) Do not screen women younger than 21 years of age. Stop screening at age 65 if 3 normal cytology results OR 2 negative high risk HPV results in the last decade AND no history of CIN 2, 3 or cervical cancer in the last 20 years. No screening should be done after hysterectomy with removal of the cervix, unless there is a history of CIN 2 or greater in the last 20 years. Patients who have had supracervical hysterectomy should continue to have routine screening. 32 15. Mammography Screening – Asymptomatic women are those who currently do not have any breast complaints. This excludes women who have symptoms which include but are not limited to breast pain, nipple discharge and breast skin changes such as dimpling, and/or new masses. Women who are high risk and therefore do not meet the guidelines above are those with: High Risk Factor Personal History of Breast Cancer (includes invasive ductal, lobular and DCIS) Breast Biopsy with Atypia or LCIS First Degree relative with invasive breast cancer Prior Chest Wall Radiation between ages 10 and 30 for treatment of cancer such as Hodgkins Known BRCA 1 or 2 genetic mutation Family history of 2 family members with breast cancer at any age from the same side of the family (maternal or paternal) Screening Recommendation Annual unless indicated by oncology physicians Annual unless indicated by oncology physicians 5 years earlier than the affected family member or at age 40; mammograms every 1-2 years Annual at 8 years post therapy or age 40 Annual at age 25 Annual mammogram beginning 5 years prior to the earliest diagnosis or age 40 The following is a list of moderate risk factors for breast cancer. They may play a role in determining when to obtain mammograms for screening but are still undergoing investigation to determine how important a role they play in the screening process: 1. Moderate to extreme breast density based on a screening mammogram 2. Obesity-BMI greater than 30 3. Alcohol intake on average of two drinks per day 4. Nulliparity 5. First birth after age 30 6. Menstrual cycles that started prior to age 12 7. Menopause that ended after age 55 33 8. Genetic Risk Factors a. Family history of one family member with epithelial ovarian cancer (maternal or paternal) b. Family history of a male with breast cancer c. Ashkenazi Jewish Heritage d. Family history with one individual with breast cancer and any additional individuals with cancers such as thyroid, sarcoma, endometrial, pancreatic, gastric, lymphoma/leukemia If a woman has one or several of these risk factors these factors should be considered in the shared decision making discussion regarding the use of screening mammography in the 40-49 and 75-85 age ranges and should be factored into the shared decision making for annual mammography for women in the 50-74 year old age range. 16. Osteoporosis – Recommend women aged 65 and older be screened routinely. Recommend routine screening for women who are post menopausal but under age 65 if they are at increased risk for osteoporotic related fractures.(Grade B Recommendation, USPSTF)67 Risk factors include but are not limited to: family history of osteoporosis or personal history of fractures, low body weight, diabetes, steroid use, rheumatoid arthritis, alcohol and tobacco use. May use FRAX calcualation to estimate 10 year risk for major fracture. 68 http://www.shef.ac.uk/FRAX/tool.jsp?country=9#notes 17. Screen for Violence – Screen women of childbearing age for intimate partner violence, such as domestic violence and provide or refer women who screen positive to intervention services. (Grade B Recommendation, USPSTF) 69 ADULT IMMUNIZATIONS Please refer to the Recommended Adult Immunization Schedule, by Vaccine and Medical and Other Indications approved by the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Nurse-Midwives. The Schedule is provided in its entirety at the Centers for Disease Control website at: http://www.cdc.gov/vaccines/schedules/hcp/adult.html70 34 ADULT HEALTH EDUCATION AND COUNSELING Injury Prevention Urge avoidance of driving after use of alcohol, illicit drugs or non-prescribed addictive drugs. Advocate use of seat belts, air bags and avoid texting while driving, as well as use of a helmet when biking, skiing, snowboarding or motorcycling. Use personal flotation devices for watercraft sports. Encourage avoidance of sun, or use of protective clothing and sunscreen (at least SPF 15) while in the sun. EDUCATION/COUNSELING Advise tobacco users to stop; counsel non-smokers to never start. Discuss availability of nicotine replacement therapies and medications as an adjunct to counseling. Please refer to the Physicians Plus Tobacco Cessation Guideline at http://www.pplusic.com listed under Clinical Practice Guidelines.(Grade A Recommendation)71 Ask about alcohol use using the “quantity-frequency” questions; if the patient is at risk for developing alcohol-related problems ask the questions for: AUDIT http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf ASSIST http://www.who.int/substance_abuse/activities/assist_technicalreport_phase2_final. pdf SIP-AD or SDS http://www.who.int/substance_abuse/research_tools/severitydependencescale/en/in dex.html SIP-AD and SDS questions need to be administered together. Assess answers to determine the severity of the problem and advise and assist as appropriate; if necessary, arrange treatment or follow-up. For additional information on alcohol screening, please refer to the Physicians Plus Alcohol Assessment and Intervention Guideline at: http://www.pplusic.com listed under Clinical Practice Guidelines. Recommend avoidance of heavy alcohol consumption. Promote a balanced diet high in fruits, vegetables, grains and fiber while low in fat and cholesterol, and encourage adequate, age-appropriate calcium intake. Maintain caloric balance. Recommend an active lifestyle with regular exercise. (Grade C Recommendation, USPSTF)72 Suggest regular dental visits and regular brushing and flossing. 35 Recommend the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (Grade A Recommendation, USPSTF)73 Recommend the use of aspirin for women age 55 to 79 years when the potential benefit due to a reduction in stroke outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (Grade A Recommendation, USPSTF)73 Recommend women whose family history is associated with an increased risk (breast or ovarian cancer) for deleterious mutations in BRCA1 or BRCA2 genes are referred for genetic counseling and evaluations for BRCA testing. (Grade B Recommendation, USPSTF)74 Additional information under Clinical Considerations http://www.uspreventiveservicestaskforce.org/uspstf05/brcagen/brcagenrs.htm#clinical Recommend high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adults at increased risk of STIs.75 (Grade A Recommendation, USPSTF) WEB SITES If you are unable to access the Physicians Plus website, you can find a similar copy of this guideline on these Web sites: Unity Health Insurance: http://www.unityhealth.com/ under Providers, Practitioner Resources, Clinical Guidelines Group Health Cooperative: https://ghcscw.com/clinical_practice_guidelines.asp Or, you can contact Physicians Plus at (608) 282-8900 to request this guideline sent to your email or mailed in hard copy format. 36 References for Supporting Evidence 1. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services Task Force. Folic Acid to Prevent Neural Tube Defects. 2009. <http://www.uspreventiveservicestaskforce.org/uspstf. Accessed December 2012. 2. Kirkham, Colleen, Susan Harris, et al. "Evidence-Based Prenatal Care: Part II. Third-Trimester Care and Prevention of Infectious Diseases." American Family Practice. 71.8 (2005): 1555-1560. Print. <http://www.aafp.org/afp/2005/0415/p1555.html>. 3. "FAQ Group B Streptococcus and Pregnancy." American College of Obstetricians and Gynecologists. FAQ 105. (2011): n. page. Print. <http://www.acog.org/~/media/For Patients/faq105.pdf?dmc=1&ts=20121210T1620390680>. Accessed November 2012. 4. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse. 2004. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm>. Accessed December 2012. 5. Department of Health and Human Services. Centers for Disease Control and Prevention. Updated recommendation. 2012. Print. <http://www.cdc.gov/vaccines/recs/provisional/downloads/Tdap-pregnant-Oct2012.pdf>. 6. Department of Health and Human Services. Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged <12 Months. Morbidity and Mortality Weekly Report (MMWR), 2011. <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6041a4.htm?s_cid=mm6041a 4_e&source=govdelivery>. 37 7. "Update on Immunization and Pregnancy: Tetanus, Diptheria, and Pertussis Vaccination." The American College of Obstetricians and Gynecologists Committee Opinion. 521. (2012): n. page. Print. <http://www.acog.org/~/media/Committee Opinions/Committee on Obstetric Practice/co521.pdf?dmc=1&ts=20120423T1657138649>. 8. Department of Health and Human Services. Centers for Disease Control and Prevention. Guidelines for Vaccinating Pregnant Women. 2011. Print. <http://www.cdc.gov/vaccines/pubs/preg-guide.htm>. 9. "Practice Bulletin Hemoglobinopathies." American Congress of Obstetricians and Gynecologists. (2007): n. page. Print. 10. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services Task Force. Counseling and Interventions to Prevent Tobacco Use and TobaccoCaused Disease in Adults and Pregnant Women. 2009. Print. <http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm>. 11. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services Task Force. Primary Care Interventions to Promote Breastfeeding. 2008. Print. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrfd.htm>. 12. "U.S. Preventive Services Task Force." American Academy of Family Practice. 74.3 (2006): 461-464. Print. <http://www.aafp.org/afp/2006/0801/p461.html>. 13. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services Task Force. Universal Screening for Hearing Loss in Newborns. 2008. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsnbhr.htm>. 14. Wisconsin State Laboratory of Hygiene. Health Professionals Guide to Newborn Screening. 2011. Web. <http://www.slh.wisc.edu/newborn/guide/>. 15. Policy Revision Committee. "Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening." American Academy of Pediatrics. 118. (2006): n. page 405-420. Print. 16. Johnson, Chris, and Scott Myers. "Identification and Evaluation of Children with Autism Spectrum Disorders." Pediatrics Journal. 120. (2007): 1183-1215. Print. 17. "Clinical Report—Hearing Assessment in Infants and." American Academy of Pediatrics. 124. (2009): 1252-1263. Web. 11 Dec. 2012. 38 18. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services. Screening for Visual Impairment in Children Ages 1 to 5 Years . 2011. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsvsch.htm>. 19. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Obesity in Children and Adolescents . 2011. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspschobes.htm>. 20. American Academy of Pediatrics. Red Book Atlas of Pediatric Infectious Diseases. 1. 2007. Table 3.76. Print. 21. Department of Health and Human Services. Centers for Disease Control and Prevention. Child, Adolescent & "Catch-up" Immunization Schedules. Web. <http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html>. 22. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services Task Force. Behavioral Counseling to Prevent Skin Cancer. 2012. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsskco.htm>. 23. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted Infections. 2008. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm>. 24. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for HIV . 2005. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm>. 25. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Obesity in Children and Adolescents. 2010. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspschobes.htm>. 26. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Major Depressive Disorder in Children and Adolescents. 2009. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm>. 27. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for High Blood Pressure in Adults. 2007. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspshype.htm>. 39 Lipid References 28-37 28. Cooper, Neil, J Betteridge, et al. "European Heart Journal."Reductions in allcause, cancer, and coronary mortality in statin-treated patients with heterozygous familial hypercholesterolaemia: a prospective registry study. 29.21 (2008): 26252633. Web. 27 Nov. 2012. <http://eurheartj.oxfordjournals.org/content/29/21/2625.full>. 29. Marks, Dayla, David Wonderling, et al. "BMJ Group." Cost effectiveness analysis of different approaches of screening for familial hypercholesterolaemia. 324.7349 (2002): n. page. Web. 27 Nov. 2012. <http://www.bmj.com/content/324/7349/1303>. 30. Marks, D, M Thorogood, et al. National Institute of Health. National Center for Biotechnology Information. . Comparing costs and benefits over a 10 year period of strategies. J Public Health Med, 2003. Web. <http://www.ncbi.nlm.nih.gov/pubmed/12669918>. 31. McCrindle, Brian, Patrick McBride, et al. "Pediatrics." Guidelines for Lipid Screening in Children and Adolescents: Bringing Evidence to the Debate. 130.2 (2012): 353-356. Web. 27 Nov. 2012. <http://pediatrics.aappublications.org/content/130/2/353.full.pdf html>. 32. Nherera, L, D Marks, et al. "Heart and Education in Heart." Probabilistic costeffectiveness analysis of cascade screening for familial hypercholesterolaemia using alternative diagnostic and identification strategies. 97.14 (2011): n. page. Web. 27 Nov. 2012. <http://heart.bmj.com/content/97/14/1175.long>. 33. Nherera, L, NW Calvert , et al. "Current Medical Research and Opinions." Cost effectivenessanalysis of the use of a high intensity statin compared to a lowintensity statin in the management of patients with familial hypercholesterolaemia. 26.3 (2010): 529-536. Web. 27 Nov. 2012. <http://informahealthcare.com/doi/abs/10.1185/03007990903494934>. 34. Rodenburg, Jessica, Maude Vissers, et al. 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Print. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm 38. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Colorectal Cancer. 2008. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm>. 39. Division of Public Health. Wisconsin Essential Diabetes Mellitus Care Guidelines 2012. 2012. Print. <http://www.dhs.wisconsin.gov/publications/P4/P49356.pdf 40. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Type 2 Diabetes Mellitus in Adults. 2008. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm>. 41. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women. 2009. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm>. 42. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse. 2008. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm>. 43. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Depression in Adults. 2009. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm>. 44. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for and Management of Obesity in Adults. 2012. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm>. 45. Smith, Bryce, Rebecca Morgan, et al. Department of Health and Human Services. Centers for Disease Control and Prevention. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. 2012. Web. <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1 46. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults. 2004. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspshepb.htm>. 47. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for HIV. 2005. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm>. 48. American Geriatric Society. 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. (2010): n. page. Web. 10 Dec. 2012. 41 49. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Prevention of Falls in Community-Dwelling Older Adults. 2012. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm>. 50. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Abdominal Aortic Aneurysm. 2005. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsaneu.htm>. Prostate Cancer Screening References 51-57 51. Agency for Healthcare Reseach and Quality. U.S. Preventive Services Task Force. Screening for Prostate Cancer. 2012. Web. <http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm>. 52. Department of Health and Human Services. Centers for Disease Control and Prevention. United States Cancer Statistics: 1999–2008 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2012. Print. <http://apps.nccd.cdc.gov/uscs/>. 53. Etzioni, R, A Tsodikov, et al. National Institute for Health. National Center for Biotechnology Information. The prostate cancer conundrum revisited: Treatment changes and prostate cancer mortality declines. 2012. Web. <http://www.ncbi.nlm.nih.gov/pubmed/22605665>. 54. Etzioni, R, A Tsodikov, et al. National Institute for Health. National Center for Biotechnology Information. Quantifying the role of PSA screening in the US prostate cancer mortality decline. 2008. Web. <http://www.ncbi.nlm.nih.gov/pubmed/18027095>. 55. Ganz, P, and W Burke. U.S. Department of Health and Human Services. National Institutes of Health. NIH State-of-the-Science Conference: Role of Active Surveillance in the Management of Men With Localized Prostate Cancer. NIH Consensus State Sci Statements:. 2011. Print. <http://consensus.nih.gov/2011/prostate.htm>. 56. Hamilton, Ann, and Lynn Ries. U.S. Department of Health and Human Services. National Cancer Institute. Cancer Survival Among Adults: U.S. Seer Program, 1988-2001. Betesda, MD: SEER Program, 2007. Print. <http://seer.cancer.gov/publications/survival/>. 57. Hugosson, Jonas, Sigrid Carlsson, et al. "The LANCET Oncology." Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. 11.8 (2010): 725-732. Web. 27 Nov. 2012. <http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(10)701467/abstract>. 58. Department of Health and Human Services. Centers for Disease Control and Prevention. 2010 STD Treatment Guidelines. 2010. Print. <http://www.cdc.gov/std/treatment/2010/>. 42 59. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Chlamydial Infection. 2007. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm> Cervical Cancer Screening References 60-66 60. Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force. Screening for Cervical Cancer. 2012. Available at: http://www.uspreventiveservicestaskforce.org/uspstf. 61. "The American College of Obstetricians and Gynecologists Women's Health Care Physicians Committee Opinion." Letter 463 of Cervical Cancer in Adolescents: Screening, Evaluation, and Management. 2010. Print. <http://www.acog.org/Resources_And_Publications/Committee_Opinions/Commi ttee_on_Adolescent_Health_Care/Cervical_Cancer_in_Adolescents__Screening_Evaluation_and_Management>. 62. "New Cervical Cancer Screening Recommendations from the U.S. Preventive Services Task Force and the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology." The American Congress of Obstetricians and Gynecologists. N.p., 12 2012. Web. 27 Nov 2012. <http://www.acog.org/About_ACOG/Announcements/New_Cervical Cancer_Screening_Recommendations 63. Rijkaart, Dorien, and Johannes Berkhof. "The LANCET Oncology." Human Papillomavirus testing for the detection of high-grade cervical intraepithelial neoplasia and cancer: final results of the POBASCAM randomized controlled trial. 13.1 (2011): 78-88. Print. <http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(11)702960/abstract>. 64. Saslow, Debbie, Diane Solomon, et al. “American Society for Colposcopy and Cervical Pathology and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer.“ American Society of Clinical Pathology. 137. (2012): 516-542. Print. <http://ajcp.ascpjournals.org/site/misc/pdf/Screening_Guidelines.pdf>. 65. Xian Wen, Jin, Andrea Skion, et al, et al. "Cleveland Clinic Journal of Medicine." Cervical Cancer Screening: Less testing, Smarter Testing. 78.11 n. page. Web. 27 Nov. 2012. <http://www.clevelandclinicmeded.com/online/journal/11_November2011/0530972/>. 66. Whitlock, Evelyn, Kimberly Vesco, et al. "Annals of Internal Medicine." Liquid Based Cytology and HPV Testing to Screen for Cervical Cancer: A Systematic Review for the US Preventive Services Task Force. 155.10 (2011): 687-697. Web. 27 Nov. 2012. <http://annals.org/article.aspx?articleid=1033158>. 43 67. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Osteoporosis. 2011. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm>. 68. World Health Organization Collaborating Centre for Metabolic Bone Diseases. University of Sheffield, UK : , Web. <http://www.shef.ac.uk/FRAX/tool.jsp?country=9 69. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Screening for Family and Intimate Partner Violence. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsfamv.htm>. 70. Department of Health and Human Services, Centers for Disease Control and Prevention. (2010). Adult immunization schedule Retrieved from http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm#hcp 71. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women. 2009. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm>. 72. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults. 2012. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsphys.htm>. 73. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Aspirin for the Prevention of Cardiovascular Disease. 2009. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm>. 74. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian Cancer Susceptibility. 2005. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrgen.htm>. 75. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted Infections. 2008. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm>. 44 Benefits/Harms of Implementation Potential Benefits: In general this guideline will provide a systematic approach to screening for and identifying preventive diseases. Specific potential benefits and potential harms of individual tests must be discussed by the provider at the time of recommendation. Appropriate use of comprehensive approach of preventive services, counseling and education and disease screening for average risk, asymptomatic patients will result in an increase in patients who are up to date with preventive services. Potential Harms: Aspirin chemoprophylaxis- aspirin therapy has been associated with an increase in gastrointestinal bleeding and hemorrhagic stroke. Prostate cancer screening is associated with potential harms including frequent false positives, leading to undue anxiety, unnecessary biopsies, and complications of treatment of some cancers that may have not affected the patient’s health. Breast cancer screening is associated with potential harms of false positive mammograms, unnecessary biopsies and anxiety. Screening tests may lead to potential harm (from the study itself or as a result of the findings on the screening study). This guideline does not provide detailed review of the potential harms of every screening study or recommendation. References are provided for detailed information. Qualifying Statements (optional) This clinical guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients and is not intended either to replace a clinician’s judgment or to establish a protocol for all patients with a particular condition. A guideline will rarely establish the only approach to a problem. Implementation Strategy Distribute to physician leads, directors and clinic managers and encourage discussion in staff meetings. Publicize new guidelines in the Physicians Plus Provider Newsletter. 45 Implementation Tools/Plan Update links to the guideline on Physicians Plus’ website. Disclaimer This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. Screening should always be considered in the context of comorbidities and anticipated life expectancy. Decisions could be made on case by case basis and screening may be discontinued as appropriate. 46 Apendix A Preventive Health Guideline Workgroup Members 2012 Physician Champion Clinical Sally Kraft, MD Center for Clinical Knowledge Management Cheryl Schutte, MBA Steering Committee Deloris Emspak, MD Mary Landry, MD Joel Buchanan, MD Julie Fagan, MD Juanita Halls, MD Prasanna Raman, MD Mihai Teodorescu, MD David Feldstein, MD Sally Kraft, MD Irene Hamrick, MD Jonas Lee, MD Richard Brown, MD Jennie Hounshell, MD Jon Keevil, MD Richard Roberts, MD Elaine Rosenblatt, NP Kim Miller, MD Meghan Ogden, MD Cheryl Schutte Anna Dopp Lisa Sherven, RN Kim Volberg, RN Heather Mantzke Jake Aleckson Pam Kittleson Bryan Gladding Susan Marks Specialty Work Groups Cervical Cancer Screening Workgroup Ann Evensen, MD Jim Eastman, MD Jimmie Stewart, MD Julie Fagan MD Kim Miller MD,GYN Meghan Ogden MD, GYN Lipid Screening Pat McBride, MD Irene Hamrick, MD Juanita Halls, MD Adult and Pediatric Immunization Jim Conway, MD Jon Temte, MD Sandy Jacobson Immunization Task Force PSA Screening Workgroup David Jarrard, MD Stephen Nakada, MD Jonas Lee, MD Juanita Halls, MD Irene Hamrick, MD David Feldstein, MD Breast Cancer Screening WorkgroupLee Wilke, MD Bill Caplan, MD Beth Burnside, MD Betsy Trowbridge, MD Pediatric Workgroup Steve Koslov, MD Jeff Sleeth, MD Prasanna Raman, MD Jennie Hounshell, MD 47 Expert Contributors Expertise Lung Cancer Screening Colon Cancer Screening Depression Screening Diabetes Screening Drug Policy Program Laboratory (Domain) Radiology (Domain) Nutrition (Domain) Respiratory (Domain) Quality Safety Innovation (Domain) Rehab Therapy (Domain) Osteoporosis Screening Experts Mark Schiebler, MD Pat Pfau, MD Perry Pickhardt, MD Roseanne Clark, MD Melissa Meredith, MD Anna Dopp Teresa Darcy, MD Keith Hoerth Gina Greenwood Jane Dunn Anne Flaten (adult) Michael Phillips Rhonda Yngsdal-Krenz (peds) Rianna Murray Noreen Poirer Neil Binkley, MD 48