Download 2013‐16 Recommendations of the US Preventive Services Task Force

2013‐16 Recommendations of the U.S. Preventive Services Task Force
Steven Ornstein, MD
Founder, PPRNet
Professor of Family Medicine
Medical University of SC
Agenda
• To present recent (2013‐16) recommendations of the USPSFT relevant to PPRNet
– CQM currently in PPRNet reports
– CQM that could be added to PPRNet reports
© PPRNet 2016
The U.S. Preventive Services
Task Force (USPSTF)
An independent panel of non‐federal experts in prevention and evidence‐based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, OB‐
GYN, nurses, and health behavior specialists).
http://www.uspreventiveservicestaskforce.org/
uspstopics.htm
© PPRNet 2016
USPSTF Recommendation Grades
A
The USPSTF recommends the service. There is high certainty that the net benefit is
substantial.
B
The USPSTF recommends the service. There is high certainty that the net benefit is moderate
or there is moderate certainty that the net benefit is moderate to substantial.
C
The USPSTF recommends selectively offering or providing this service to individual patients
based on professional judgment and patient preferences. There is at least moderate certainty
that the net benefit is small.
D
The USPSTF recommends against the service. There is moderate or high certainty that the
service has no net benefit or that the harms outweigh the benefits.
I
The USPSTF concludes that current evidence is insufficient to assess the balance of benefits
& harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of
benefits and harms cannot be determined.
statement
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www.aafp.org/afp/2016/0501/p738.html
http://epss.ahrq.gov/PDA/index.jsp
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Abnormal Blood Glucose and Type 2 Diabetes Mellitus Screening in Adults
Release Date: October, 2015
From 2009‐12, 37% of U.S. adults aged 20 years or older had IFG or IGT and 12% had DM.
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Clinical Summary
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Persons who have a family history of DM, have a history of gestational DM or polycystic ovarian syndrome, or are members of certain racial/ethnic groups (that is, African Americans, American Indians or Alaskan Natives, Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders) may be at increased risk for DM at a younger age or at a lower body mass index. Clinicians should consider screening earlier in persons with 1 or more of these characteristics.
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Healthful Diet and Physical Activity for CVD Prevention in Adults With CVD Risk Factors: Behavioral Counseling
Release Date: August 2014
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Clinical Summary
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What Does “Intensive” Mean?
Medium‐intensity:
• Median of 5 contacts and 9 month duration
• 31 to 360 minutes of interaction time with a clinician
High‐intensity:
• Median 16 contacts and 12 month duration
• >360 minutes of contact time
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High Blood Pressure Screening
Release Date: October 2015
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Clinical Summary
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Ambulatory Vs. Home BP Monitoring to Confirm Dx
• USPSTF considers ABPM to be the reference standard for confirming the diagnosis of hypertension.
• Use of ABPM may be problematic in some situations.
• Home blood pressure monitoring using appropriate protocols is an alternative method of confirmation if ABPM is not available. Measurements from the office, HBPM, and ABPM all must be interpreted with care and in the context of the individual patient. • Patients with very high blood pressure or signs of end‐organ damage may need immediate treatment.
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Statin Use for the Primary Prevention of Cardiovascular Disease in Adults
Draft Release Date: December 2015
Adults ages 40–75 yrs with no symptoms or history of CVD and
a calculated 10-year CVD event risk of ≥10%
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Statin Use for the Primary Prevention of Cardiovascular Disease in Adults
Draft Release Date: December 2015
Adults ages 40–75 yrs with no symptoms or history of CVD and
calculated 10-year CVD event risk of 7.5-10%
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Considerations
No clinical trials have evaluated statin use in adults on the basis of a specific risk threshold calculated by a CVD risk prediction tool. In addition, the incidence of CVD events in the population increases linearly with CVD risk level; there is no point at which event rates abruptly escalate. The likelihood that an individual will benefit from statin use largely depends on his or her absolute baseline risk of a CVD event. Although regular statin use may reduce the risk of a CVD event when the predicted 10‐year risk is less than 10%, the number of persons who will avert a CVD event will be much smaller than when that risk is at least 10%, and clinicians’ ability to accurately identify who will go on to experience a CVD event is limited. Persons who place a higher value on the potential benefits than the potential harms and inconvenience of taking a daily medication may choose to initiate statin use for cardiovascular risk © PPRNet 2016
reduction.
Statin Use for the Primary Prevention of Cardiovascular Disease in Adults
Draft Release Date: December 2015
Adults age 76 years and older without a history of heart attack or stroke
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Abdominal Aortic Aneurysm: Screening
Release Date: June 2014
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Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer
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Clinical Summary
© PPRNet 2016
No Current PPRNet CQM for this USPSTF recommendation
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HIV Infection: Screening
Release Date: April 2013
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Screening Intervals
The evidence is insufficient to determine optimum time intervals for HIV screening. One reasonable approach would be one‐time screening of adolescent and adult patients to identify persons who are already HIV‐positive, with repeated screening of those who are known to be at risk for HIV infection. Patient populations that would more likely benefit from more frequent testing include those who are known to be at higher risk for HIV infection, those who are actively engaged in risky behaviors, and those who live in a high‐prevalence setting (>1%). © PPRNet 2016
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Hepatitis C: Screening
Release Date: June 2013
© PPRNet 2016
May 4, 2016
• Hepatitis C Kills More Americans than Any Other Infectious Disease
• 19,659 deaths in 2014
• Hepatitis C‐related mortality in 2013 surpassed the total combined number of deaths from 60 other infectious diseases reported to CDC, including HIV, pneumococcal disease, and tuberculosis
• Greatest Hepatitis C burden falls on baby boomers
• New wave of hepatitis C infections among people © PPRNet 2016
who inject drugs
Risk Assessment
• The most important risk factor for HCV infection is past or current injection drug use. Additional risk factors include receiving a blood transfusion before 1992, long‐
term hemodialysis, being born to an HCV‐infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, and other percutaneous exposures.
• Adults born between 1945 and 1965 are more likely to be diagnosed with HCV infection, either because they received a blood transfusion before the introduction of screening in 1992 or because they have a history of other risk factors for exposure decades earlier.
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Screening Tests
Anti–HCV antibody testing followed by confirmatory polymerase chain reaction testing accurately identifies patients with chronic HCV infection. Various noninvasive tests with good diagnostic accuracy are possible alternatives to liver biopsy for diagnosing fibrosis or cirrhosis.
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Screening Intervals
Persons with continued risk for HCV infection (such as injection drug users) should be screened periodically. Evidence on how often screening should occur in these persons is lacking. Adults born between 1945 and 1965 and persons who are at risk because of potential exposure before universal blood screening need only be screened once.
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Chlamydia and Gonorrhea: Screening
Release Date: September 2014
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Risk Assessment
• Highest infection rates in women aged 20 to 24 years, followed by females aged 15 to 19 years. • Chlamydial infections are 10 times more prevalent than gonococcal infections in young adult women
• Other risk factors:
• New sex partner, more than 1 sex partner (or sex partner with more with 1 partner), or sex partner with STI
• Inconsistent condom use among persons who are not in mutually monogamous relationships
• Previous or coexisting STI
• Exchanging sex for money or drugs
• Incarcerated populations, military recruits, and patients receiving care at public STI clinics
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Screening Tests
• Chlamydia and gonorrhoeae infections should be diagnosed by using nucleic acid amplification tests (NAATs)‐‐high sensitivity and specificity
• Done on urine specimen, clinician‐collected endocervical, vaginal, and male urethral specimens
• Most NAATs approved for clinician collected vaginal specimen can use self‐collected vaginal specimens in clinical settings. © PPRNet 2016
Screening Intervals
• No adequate studies
• “Reasonable approach would be to screen patients whose sexual history reveals new or persistent risk factors since the last negative test result”
• CDC recommends annual screening for those at risk
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BRCA‐Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing
Release Date: December 2013
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Risk Assessment
• Family history factors associated with increased likelihood of potentially harmful BRCA mutations include breast cancer diagnosis before age 50 years, bilateral breast cancer, family history of breast and ovarian cancer, presence of breast cancer in ≥1 male family member, multiple cases of breast cancer in the family, ≥1 or more family member with 2 primary types of BRCA‐
related cancer, and Ashkenazi Jewish ethnicity.
• Several familial risk stratification tools are available to determine the need for in‐depth genetic counseling, such as the Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, and FHS‐7.
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Referral Screening Tool
https://www.breastcancergenescreen.org/public.aspx
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Screening Tests
• Genetic risk assessment and BRCA mutation testing are generally multistep processes involving identification of women who may be at increased risk for potentially harmful mutations, followed by genetic counseling by suitably trained health care providers and genetic testing of selected high‐risk women when indicated.
• Tests for BRCA mutations are highly sensitive and specific for known mutations, but interpretation of results is complex and generally requires posttest counseling.
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Interventions in Women with BRCA Mutations
• More frequent, or intensive cancer screening (evidence absent)
• Tamoxifen or raloxifene: reduce the incidence of invasive breast cancer in high‐risk women in the general population, not studied specifically in women who are BRCA mutation carriers
• Mastectomy: 85% to 100% reduction of breast cancer risk
• Salpingo‐oophorectomy:
• 37% to 100% reduction in breast cancer risk
• 69% to 100% in ovarian cancer risk
• Up to 55% relative reduction in all‐cause mortality
© PPRNet 2016
No Current PPRNet CQM for these USPSTF recommendation
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Breast Cancer: Medications for Risk Reduction
© PPRNet 2016
Risk Assessment
• Important risk factors for breast cancer include age, race/ethnicity, age at menarche, age at first live childbirth, personal history of ductal or lobular CIS, number of first‐degree relatives with breast cancer, personal history of breast biopsy, BMI, menopause status or age, breast density, estrogen and progestin use, smoking, alcohol use, physical activity, and diet.
• Available risk assessment models can accurately predict the number of breast cancer cases that may arise in certain study populations, but their ability to accurately predict which women will develop breast cancer is modest.
© PPRNet 2016
www.cancer.g
ov/bcrisktool/
Those with 5 year risk of 3% or greater may benefit from risk reduction medication
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Interventions
• Selective estrogen receptor modulators (tamoxifen and raloxifene) have been shown to reduce the incidence of invasive breast cancer in several RCTs. Tamoxifen has been approved for this use in women >= 35 years; raloxifene for postmenopausal women.
• Doses for tamoxifen and raloxifene are 20 mg and 60 mg, respectively, for 5 years. • Tamoxifen is not recommended for use in combination with hormone therapy or hormonal contraception or in women who are pregnant, those who may become pregnant, or breastfeeding mothers.
© PPRNet 2016
No Current PPRNet CQM for this USPSTF recommendation
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Breast Cancer: Screening
Release Date: January, 2016
© PPRNet 2016
Breast Cancer: Screening
• For women who are at average risk for breast cancer,
most of the benefit of mammography results from
biennial screening during ages 50 to 74 years.
• Women aged 60 to 69 years are most likely to avoid
breast cancer death through mammography
screening.
• While screening mammography in women aged 40 to
49 years may reduce the risk for breast cancer death,
the number of deaths averted is smaller than that in
older women and the number of false-positive results
and unnecessary biopsies is larger.
• The balance of benefits and harms is likely to improve
as women move from their early to late 40s.
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Breast Cancer: Screening
• All women undergoing regular screening
mammography are at risk for the diagnosis and
treatment of noninvasive and invasive breast cancer
that would otherwise not have become a threat to
their health, or even apparent, during their lifetime
(over-diagnosis).
• Beginning mammography screening at a younger age
and screening more frequently may increase the risk
for over-diagnosis and subsequent overtreatment.
© PPRNet 2016
Breast Cancer: Screening
• Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average‐risk women from beginning screening in their 40s.
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Breast Cancer: Screening
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Colorectal Cancer Screening
Release Date: June 2016
© PPRNet 2016
Screening Tests
There are numerous screening tests to detect early‐stage colorectal cancer, including stool‐based tests (gFOBT, FIT, and FIT‐DNA), direct visualization tests (flexible sigmoidoscopy, alone or combined with FIT; colonoscopy; and CT colonography), and serology tests (SEPT9DNA test). The USPSTF found no head‐to‐head studies demonstrating that any of these screening strategies are more effective than others, although they have varying levels of evidence supporting their effectiveness, as well as different strengths and limitations.
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Stool Based Tests
Method
Freq
Efficacy Evidence © PPRNet 2016
Other considerations
Direct Visualization Tests
Method
Freq
Efficacy Evidence © PPRNet 2016
Other considerations
Benefits of CRC Screening
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Benefits of CRC Screening
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Harms of CRC Screening
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Burdens of CRC Screening
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Current PPRNet CQM for CRC Screening does not include CT‐
Colonography, FIT‐DNA, or Serology Tests
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Lung Cancer: Screening
Release Date: December 2013
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Importance of Lung Cancer
• Third most common cancer and the leading cause of cancer death in the U.S.
• Smoking is most important risk factor; causes 85% of all U.S. cases, risk is cumulative • 37% of U.S. adults are current or former smokers
• Most commonly in persons aged 55 years or older
• Poor prognosis; 90% die of the disease
• However, early‐stage non–small cell lung cancer (NSCLC)—most common type‐‐ has a better prognosis and can be treated
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Patient Population Under Consideration
• NLST enrolled adults aged 55 to 74 years with >= 30 pack‐
year hx‐‐ current smokers or had quit <15 years
• Modelling studies indicate program that annually screens adults aged 55 to 80 years has a reasonable balance of benefits and harms • Screening may not be appropriate for patients with substantial comorbid conditions, particularly those who are in the upper end of the screening age range. The NLST excluded persons who were unlikely to complete curative lung cancer surgery and those with medical conditions that posed a substantial risk for death during the 8‐year trial
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National Lung Cancer Screening Trial
• Chest X‐ray vs Low dose CT • CXR = Sensitivity 73.5%, specificity 91.3% for detecting lung cancer
(9.2% positive screening result, 0.7% diagnosed with lung cancer)
• LDCT = Sensitivity 93.8%, specificity 73.4% for detecting lung cancer
(27.3% positive screening result, 1.1% diagnosed with lung cancer)
• Around 95% of all positives were false positives for CXR and CT
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Benefits of Early Detection/ Treatment
• Screening is not an alternative to smoking cessation; screening cannot prevent most LC deaths; smoking cessation intervention should be before referral for screening
• Annual screening for LC with LDCT in a defined population of high‐risk persons can prevent a substantial number of LC–
related deaths—16% reduction in LC mortality; 6.7% all cause (NLST)
• Magnitude of benefit depends on risk for lung cancer because those who are at highest risk are most likely to benefit
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Harms of Early Detection/Treatment
• Over 3 years of screening in NLST around a quarter of tests were positive; False positive—96.4% in NLST
• In a high‐quality program, further imaging can resolve most false‐pos results; however, some pts may require invasive procedures—2.5% of positive tests in NLST.
• Insufficient evidence on the harms associated with incidental findings. • Over diagnosis‐‐estimated that 10% to 12% of screen‐
detected cancer cases they would not have been detected in the patient's lifetime without screening. • Radiation harms, including cancer, vary depending on the age at the start of screening; the number of scans received; and the person's exposure to other sources of radiation, particularly other medical imaging
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Overall Assessment
• Moderate certainty that annual screening for LC with LDCT is of moderate net benefit in asymptomatic persons who are at high risk based on age, cumulative exposure to tobacco smoke, and years since quitting smoking
• Moderate net benefit of screening depends on limiting screening to persons who are at high risk, the accuracy of image interpretation being similar to that found in the NLST and the resolution of most false‐positive results without invasive procedures
© PPRNet 2016
No Current PPRNet CQM for this USPSTF recommendation
© PPRNet 2016
Depression Screening
Release Date: Jan 2016 (Adults), Feb 2016 (Adolescents)
© PPRNet 2016
Importance of Depression
• Among the leading causes of disability in persons >=15 years
• Affects individuals, families, businesses, and society
• Common in patients seeking care in the primary care setting
• Common in postpartum and pregnant women; affects child as well
• Associated with increased mortality due to suicide, impact on treatment of other illness
• High direct and indirect costs
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Adults
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Risk Assessment
• Although some populations are at higher risk of depression, based on socioeconomic, health status, and other factors, all adults are at risk and should be screened
© PPRNet 2016
Screening Tests
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Patient Health Questionnaire (PHQ) in various forms
Hospital Anxiety and Depression Scales in adults
Geriatric Depression Scale in older adults
Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women
• All positive screens need additional assessment:
• Severity
• Comorbid psychological problems (anxiety, panic attacks, or substance abuse)
• Medical conditions
• Alternate diagnoses
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www.phqscreeners.com
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PHQ‐9
• Multipurpose tool for depression:
• Screening
• Diagnosing
• Monitoring
• Measuring severity
• Owned by Pfizer but freely available without permission
© PPRNet 2016
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Scoring and Disposition
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PHQ‐2 • Purely a screening tool
• Assesses frequency of depressed mood and anhedonia in past 2 weeks—0=not at all, 3=nearly every day
• Score >=3 sensitivity 83%, specificity 92% for major depression (Med Care, Nov 2013, 41: 1284‐92)
• Those that score >=3 can be administered the PHQ‐9
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PHQ‐2
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Edinburgh Postnatal Depression Scale
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Edinburgh Postnatal Depression Scale
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Apps
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Screening Interval
• The optimum interval for screening for depression is also unknown
• Pragmatic approach
• Screening all adults not been screened previously
• Use clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high‐risk patients is warranted
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“Adequate Systems in Place”
•
•
Systems and clinical staff to ensure that patients are screened and, if they screen +, are appropriately diagnosed and treated with evidence‐
based care or referred to a setting that can provide needed care.
Wide range of different arrangements of clinician types/settings, e.g.:
• Low level‐‐Designated nurse who advised resident physicians of positive screening results and provided a protocol that facilitated referral to evidence‐based behavioral treatment
• Highest level‐‐staff and clinician training (1‐ or 2‐day workshops); clinician manuals; monthly training lectures; academic detailing; materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow‐up assessment and ongoing support for medication adherence; a visit with a trained therapist for CBT; and a reduced copayment for patients referred for psychotherapy
© PPRNet 2016
“Adequate Systems in Place”
• Multidisciplinary team–based primary care that includes self management support and care coordination has effective in management of depression
• Collaborative care and disease includes a systematic, multicomponent, and team‐based approach that “strengthens and supports self‐care, while assuring that effective medical, preventive, and health maintenance interventions take place” to improve the quality and outcome of patient care
© PPRNet 2016
Interventions
• Effective treatment includes antidepressants and/or specific psychotherapy approaches (CBT or brief psychosocial counseling)
• Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider CBT or other evidence‐
based counseling interventions when managing depression in pregnant or breastfeeding women
© PPRNet 2016
Benefits of Screening
• Programs combining depression screening with adequate support systems in place improve reduction or remission of depression in adults, including pregnant and postpartum women
• Treatment of adults and older adults with depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity
• Treatment with CBT improves clinical outcomes in pregnant and postpartum women with depression
© PPRNet 2016
Harms of Screening
• Magnitude of harms of screening for depression in adults is small to none.
• Magnitude of harms of treatment with CBT in postpartum and pregnant women is small to none
• Second‐generation antidepressants (mostly SSRIs) are associated (small risks) with some harms:
o Increase in suicidal behaviors in adults aged 18 to 29 years
o Increased risk of UGI bleeding in adults older than 70 years
o Small increased risk of adverse maternal fetal outcomes in observational studies
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Adolescents
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Clinical Summary
© PPRNet 2016
No Current PPRNet CQM for this USPSTF recommendation
© PPRNet 2016
Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions
Release Date: Sept 2015
© PPRNet 2016
Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions
Release Date: Sept 2015
© PPRNet 2016
Importance
• ~42.1 million U.S. adults (18% of the population) currently smoke
• Leading preventable cause of disease, disability, and death in the U.S.
• >480,000 premature deaths annually; accounts for 1 in every 5 deaths
• Increased risk:
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•
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•
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Lung, liver, and colorectal cancer
COPD, TB
CVD
Diabetes
Autoimmune disease
Macular degeneration
Erectile dysfunction
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Importance
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•
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23% of women smoke during the 3 months before conception
55% quit smoking during pregnancy
10% smoked during the last 3 months of pregnancy
In pregnant women increased risk of:
o Ectopic pregnancy
o Congenital anomalies
o Perinatal complications (preterm birth, fetal growth restriction, placental abruption; miscarriage and stillbirth)
o Neonatal or pediatric complications (SIDS impaired lung function in childhood)
© PPRNet 2016
Risk Assessment
• Smoking as a vital sign
• 5 A’s:
o 1) Ask about smoking
o 2) Advise to quit through clear, personalized messages
o 3) Assess willingness to quit
o 4) Assist in quitting
o 5) Arrange follow‐up and support
• AAR: Replaces steps 3) to 5) with referral to telephone quit lines and/or other evidence‐based cessation interventions
© PPRNet 2016
Benefits of Interventions: Non Pregnant Adults
• Each or both in substantially improve achievement of tobacco cessation:
o Behavioral interventions (in‐person, telephone, self‐help materials) o Pharmacotherapy (nicotine replacement therapy (NRT), bupropion hydrochloride SR, varenicline)
o Shared decision making to choose treatment
• Also:
o 2 types of NRT moderately better than 1 type o Addition of NRT to treatment with bupropion SR added benefit
o Inadequate evidence of the effect of electronic nicotine delivery systems (ENDS)
© PPRNet 2016
Benefits of Interventions: Pregnant Women
• Behavioral interventions substantially improve:
o Tobacco smoking abstinence
o Increase infant birthweight
o Reduce risk for preterm birth • Inadequate evidence on the benefits of NRT
• No evidence on the benefits of bupropion SR, varenicline, ENDS
© PPRNet 2016
Behavioral Interventions
• Dose–response relationship between the intensity of counseling and cessation—multiple sessions best
• Cessation rates may plateau after 90 minutes of total counseling contact time
• Effective interventions can be delivered by various PCP: physicians, nurses, psychologists, social workers, and cessation counselors
• Both individual and group counseling are effective
• Effective interventions provide social support and problem solving skill training
o Recognize situations that increase their risk for smoking
o Develop coping skills to overcome common barriers © PPRNet 2016
to quitting
Behavioral Interventions
• Telephone counseling interventions are effective:
– At least 3 telephone calls
– Can be provided by professional counselors or trained HCP
• Self help materials:
– Tailored to the individual patient effective
– Non‐tailored, print‐based, self‐help materials; computer‐based programs; and mobile phone–
based interventions mixed effectiveness
© PPRNet 2016
Harms of Interventions
Nonpregnant Adults
• Behavioral interventions: small to none
• NRT, bupropion SR, or varenicline: small • ENDS: inadequate evidence
Pregnant Women
• Behavioral interventions: small to none • NRT: inadequate evidence • Bupropion SR, varenicline, ENDS: no evidence
© PPRNet 2016
1‐800‐QUIT‐NOW
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Operated by the National Cancer Institute (NCI)
Partnership between NCI and CDC
Connects caller to state’s tobacco quitline
Services differ by State: http://map.naquitline.org
o Counseling
o Web‐based services
o Free medication
o Discounted medication
o Provider referrals
© PPRNet 2016
Patient Resources
http://smokefree.gov
© PPRNet 2016
Be Realistic But Not Pessimistic
• “Substantial benefit” does not mean the majority benefit
• 6 month abstinence for the best interventions are in the ~17%‐28% range, compared with ~8‐12% in the comparison groups
• So most patients do not become abstinent from any particular approach at any one time
• However, they may become abstinent at some point so repeated interventions are recommended.
© PPRNet 2016
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Questions and Comments
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