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Education

Most common and preventable conditions:

Cardiovascular disease — Because cardiovascular disease (CVD) is the most common cause of death in the United States, clinicians should consider counseling for prevention of heart attack and stroke in all patients ages 35 and older. Patients who are obese or physically inactive and patients with cardiovascular risk factors should be especially targeted.

A small number of preventive services, if delivered routinely, could have a major impact on mortality and morbidity from CVD.

  • Assess each patient’s absolute risk of having a CVD event (also called “global CVD risk”) using one of several widely available statistical tools. In general, one should intervene most aggressively to reduce risk factors among patients at high global risk (ie, ≥20 percent 10-year risk). Patients with low risk need little intervention. For patients at moderate to high CVD risk (ie, 10 to 19 percent 10-year risk), three pharmacologic interventions have been shown to reduce the risk of CVD: antihypertensive drugs for patients who are not at blood pressure goal, statin therapy, and low-dose aspirin.
  • The net benefit of assessing risk with nontraditional risk factors has not been established, and we do not recommend general population screening for these factors, which may include highly-sensitive C-reactive protein (hs-CRP), ankle-brachial index (ABI), white blood count, fasting glucose, presence of periodontal disease, carotid artery intima-media thickness, electron beam CT scan (EBCT), homocysteine, or lipoprotein.
  • Lifestyle education should be provided to all patients to promote maintenance of healthy weight and physical activity. To help obese or sedentary patients adopt a healthier lifestyle, more intensive behavioral counseling is needed. Brief counseling within primary care for smoking cessation increases quit rates and decreases CVD risk.

Hypertension — Hypertension in the US accounts for 35 percent of myocardial infarctions and strokes, 49 percent of episodes of heart failure, and 24 percent of premature deaths. High blood pressure is diagnosed when systolic blood pressure (SBP) is ≥140 mmHg or diastolic blood pressure (DBP) is ≥90 mmHg on two or more visits over a period of several weeks

There is clear evidence that treatment of high blood pressure can decrease the incidence of cardiovascular disease. Thus, the benefits of screening for and treating high blood pressure in adults substantially outweigh the harms.

Abdominal aortic aneurysm — Ruptured abdominal aortic aneurysm (AAA) is a catastrophic but uncommon event. The great majority of the 9000 annual US deaths from AAA rupture are in men between the ages of 65 and 75 years who are current or former smokers. Open surgical repair of AAA ≥5.5 cm reduces deaths associated with AAA rupture, at a cost of increased surgical procedures.

We recommend one-time ultrasound screening in men ages 65 to 75 years who are current or former smokers. One-time screening for AAA has been recommended by some for men ages 65 to 75 who have never smoked but who have a first-degree relative who required repair of or died from an AAA. The prevalence of AAA is much lower in other non-smokers, younger men, and all women, and screening is not recommended for these groups.

Peripheral artery disease — Individuals with lower extremity peripheral artery disease (PAD) are at significantly increased risk of cardiovascular and cerebrovascular mortality, and evidence suggests that the majority of cases of PAD are undetected in routine clinical practice. PAD can be reliably diagnosed by a low ankle-branchial index (ABI <0.9) using Doppler ultrasound.

Cancer morbidity and mortality — The cancers that are responsible for the greatest mortality in the US are lung, colorectal, breast, and prostate.

Prevention is most effective for cancers that are strongly and causally associated with tobacco use: cancers of the oropharynx, bladder, esophagus, and lung. Colon polyp removal with screening colonoscopy can prevent colorectal carcinoma. Treatment of precursor lesions detected at screening can prevent cervical cancer. Vaccination for HPV should also decrease the incidence of cervical cancer.

Screening for breast, cervical, or colorectal cancer can decrease cancer mortality.

Breast cancer —breast cancer screening with mammography between the ages of 50 and 75 reduces mortality from breast cancer to a small but clinically-important degree. Clinicians should target women 50 to 75 years old for discussion of the potential benefits and potential harms of screening. Screening should also be discussed with women in their 40s, although fewer women in this age group are likely to benefit.

We also suggest regular clinical breast examinations (CBE), some breast cancers are not detected by mammography; a positive CBE requires further investigation, even if the mammogram is negative. Taking time for a careful CBE increases chances of early detection.

Cervical cancer — Physicians should target women with an intact cervix, starting at age 21. Starting screening before age 21 adds little or no benefit but leads to more procedures with potential harms.

Screening for cervical cancer is done by cytological examination (for women aged 21 and older) or, in women over age 30, by a combination of cytological examination and testing for human papillomavirus (HPV). HPV testing has a greater sensitivity for detecting high-grade precancerous lesions but is associated with more false-positive tests and higher referral rates for colposcopy than cytology alone. Thus, although the combination of cytology plus HPV testing may be used for screening in women over age 30 years, cytology alone is also a reasonable strategy. HPV testing is useful to determine how to triage women with atypical squamous cells of undetermined significance (ASCUS) findings on cytology.

The optimal frequency of screening for cervical cancer is not clear, but modeling studies suggest that cytological screening every three years achieves about as much benefit as annual screening with fewer false positives and fewer procedures. Co-testing with cytology and HPV tests (in women over age 30) allows the interval to be extended to five years.

Mortality from cervical cancer is greatest among women who have not had prior adequate screening.

Colorectal cancer — Patients should be asked about first- and second-degree relatives who have had colorectal cancer. Screening and prevention recommendations for patients with a family history of colorectal cancer, as well as genetic screening, are discussed in detail elsewhere.

Screening for colorectal cancer reduces mortality from this disease. Regular screening should be initiated at age 50 for patients with an average risk for colorectal cancer and earlier for those with increased risk.

Lung cancer — Reducing the risk of lung cancer should focus on those people who smoke tobacco and on targeted populations (ie, adolescents) who are at risk of initiating tobacco use. Avoidance and cessation of tobacco use could potentially reduce the incidence and mortality from lung cancer by about 90 percent.

Brief assessment and counseling in primary care is effective in increasing quit rates.

Prostate cancer —The benefits of screening (ie, reducing prostate cancer mortality) are small in that they accrue to only a small number of men. Benefits may be outweighed by the significant harms of screening that affect many more men (need for biopsy, and impotence or incontinence occurring in at least 50 percent of men who undergo treatment for a disease that may be indolent

There is interest in screening for prostate cancer among some men; individual and informed patient preferences for identified health outcomes should guide decisions about screening. Thus, although screening for prostate cancer should generally be discouraged, it is reasonable, at least once, to initiate a discussion about screening with average risk men between 50 and 69 years of age.

Melanoma — Clinicians should remain alert for skin lesions with malignant features and refer those patients to dermatologists. Patient counseling in primary care can increase sun protective behaviors, including increased use of sunblocking agents and decreased exposure to midday sun and indoor tanning.

Depression — We recommend screening all adults for depression. When screening is combined with systems of care that assure further evaluation, treatment, and follow-up, the burden of suffering from depression can be reduced.

Diabetes mellitus — The USPSTF recommends targeted screening for people with sustained blood pressure ≥135/80. The American Diabetes Association (ADA) recommends screening for diabetes for patients age 45 and older without risk factors. The ADA also recommends testing for diabetes in adults who are overweight or obese (BMI ≥25 kg/m2) and have one or more additional risk factors for diabetes.

Influenza vaccine — We recommend annual influenza vaccination to individuals six months of age and older.

Pneumococcal vaccine — All people with chronic illness and those ages 65 years and older should be immunized against Streptococcus pneumoniae infection. Additionally, the United States Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) advises pneumococcal vaccination for cigarette smokers

Zoster vaccine — A live attenuated vaccine for herpes zoster was licensed by the US Food and Drug Administration in 2006 for use in people age 60 years and older. An estimated 30 percent of people develop herpes zoster at some point in their lives, the risk increasing with age. Post-herpetic neuralgia develops in about 40 percent of people who develop zoster over the age of 60. Preliminary data also suggest that zoster vaccine is effective in reducing the incidence of zoster in persons 50 to 59 years of age.

Hepatitis B vaccination — In 2011, the ACIP voted to recommend the hepatitis B vaccine for diabetic adults younger than 60 years and for diabetic patients older than 60 years based on their likelihood of acquiring hepatitis B, of need for assisted blood glucose monitoring, and likelihood of an immune response

Tetanus, diphtheria, and acellular pertussis vaccination (Td/Tdap) — The USPSTF recommends booster doses of adult-type tetanus and diphtheria toxoid every 10 years.

Injury prevention

Falls and bone fractures — Clinicians should target people ages 65 years and older or younger people with special risk factors (eg, previous falls or fractures).

Effectively reducing bone fractures among older people involves both preventing falls and increasing bone and muscle strength. Fall prevention includes minimizing psychotropic medications, encouraging weight-bearing physical activity and muscle strengthening, and vitamin D supplementation. Increasing bone strength involves screening women older than 65 years (or women ages 60 to 64 who are at high risk) for bone mineral density (BMD). Bisphosphonate therapy for low bone mineral density reduces fractures in women ages 65 and older. Because of the low risk of fractures in younger women, routine BMD screening is unlikely to be useful in this age group. For women 65 years of age and older with normal or slightly-low bone mass (T-score -1.01 to -1.49) at baseline measurement and no risk factors for accelerated bone loss, follow-up DXA is not needed for 10 to 15 years.

Lifestyle-related problems

Obesity and physical inactivity — Obesity (BMI >30) and physical inactivity are associated with hypertension, diabetes, increased cardiovascular events, and increased all-cause mortality.

Intentional weight reduction and increased physical activity are associated with decreased risk. Unfortunately, brief counseling interventions in clinical settings have little long-term effect on reducing weight or increasing physical activity. More intensive interventions that include nutrition education, individualized goal-setting, behavioral approaches, walking groups, and other social activities can be modestly successful. The USPSTF recommends that clinicians screen their adult patients for obesity. Patients with a body mass index ≥30 kg/m2 should be offered or referred to intensive, multidisciplinary programs for obesity and physical inactivity.

Sexually-transmitted and other blood-borne infections

Chlamydia — Sexually active women ages 15 to 25 years, and older women who have behavioral risk factors, are at highest risk of complications from chlamydia.

Genital chlamydia trachomatis is common, often asymptomatic, and can lead to serious complications including pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain. Chlamydial infection is also highly treatable. Urine-based nucleic acid amplification tests make screening simple and accurate.

We recommend screening sexually active women ages 15 to 25 years and older women who have behavioral risk factors (eg, new or multiple sexual partners, inconsistent use of barrier methods

Gonorrhea — The prevalence of asymptomatic gonorrhea in young women in the US is much lower than chlamydia infection, and tends to be centered in high risk areas. Thus, the most appropriate target group for gonorrhea screening is younger, sexually active women in high-risk areas. Clinicians therefore need to determine whether they are practicing in a high risk area, either by office testing or by consultation with the local health department.

We recommend screening sexually active women ages 15 to 29 years who live in areas of high prevalence.

Hepatitis C — Starting in 2012, the Centers for Disease Control and Prevention (CDC) recommends one time birth cohort screening for hepatitis C virus (HCV) antibodies for all persons in the United States born between 1945 and 1965.

HIV infection — Patients at increased risk for human immunodeficiency virus (HIV) infection are those who report at least one individual risk factor: men who have sex with men, people who have unprotected sex with multiple partners, past or present injection drug users, sexual contact with HIV-infected others, and people with other sexually transmitted infections. Screening should be considered for patients seen in high-risk or high-prevalence clinical settings such as sexually transmitted diseases clinics, correctional facilities, homeless shelters, emergency rooms, or tuberculosis clinics.

Institution of routine HIV screening programs must be accompanied by scrupulous attention to patient confidentiality and appropriate counseling for post-test results. In 2005, the USPSTF recommended screening for people at increased risk. A subsequent systematic review found growing evidence that antiretroviral therapy can reduce the risk of sexual transmission of HIV and reduce morbidity and mortality in all HIV-infected patients, including those who may be asymptomatic and only identified through screening. The USPSTF has issued a draft revised recommendation to screen individuals in the general population, aged 15 to 65 years, that is undergoing review in 2013.

Substance-abuse related problems

Alcohol — Alcohol misuse is common in all age groups, all socioeconomic levels, and in both genders. Alcohol consumption, above recommended daily, weekly, or per occasion amounts, is associated with multiple health problems including motor vehicle crashes, suicide, violence, hypertension, mental disorders, and development of alcohol dependence. Brief interventions in primary care, including feedback, goal setting, and follow-up with short contacts, are effective in reducing alcohol consumption to safer levels.

We recommend screening adults for alcohol problems

Tobacco — Clinicians should ask all patients whether they use tobacco, and in what form.

Tobacco contributes to over 400,000 deaths each year in the United States [2]. Stopping smoking carries both immediate and long-term benefits. We recommend brief assessment and counseling for tobacco cessation. Most importantly, clinicians should realize that stopping smoking is a process that requires time. Smokers will often “relapse” several times before stopping permanently.

Other drug use — All new patients should be asked whether they use or have used drugs that have the potential for abuse. The frequency, dose, and route of drug administration should be asked for those who acknowledge drug use. A drug history should also be reviewed for patients who present with new symptoms such as unexplained weight loss, or new mood or behavioral issues.

Injection drug users should be screened for serologic evidence of immunity to hepatitis B virus, and vaccinated for hepatitis B if nonimmune.

The Center for Disease Control, the National Institutes of Health, and other groups recommend that persons who ever injected drugs should be tested for hepatitis C virus (HCV) infection, while the US Preventive Services Task Force notes insufficient evidence to recommend for or against routine screening for HCV in adults at high risk.

Vision and hearing problems — Vision and hearing problems, severe enough to affect a patient’s function, become more common after age 65 years. Despite the fact that simple tests can detect these problems, few well-conducted studies have examined the effect of screening for these problems on function.

Because many older adults are unaware of correctable vision and hearing problems that may significantly affect their functional abilities, we think it is reasonable to periodically screen people ages 65 and older for vision and hearing problems.