Update on the Methods of the U.S. Preventive Services Task Force: Insufficient Evidence Update on the Methods of the U.S. Preventive Services Task Force: Estimating Certainty and Magnitude of Net Benefit Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Preventive health care, 1999 update: prevention of oral cancer mortality. The Canadian Task Force on Preventive Health Care. Screening for Type 2 Diabetes Mellitus in Adults: Recommendations and Rationale Prostate Needle Biopsy Outcomes in the Era of the U.S. Preventive Services Task Force Recommendation against Prostate Specific Antigen Based Screening. Screening for Family and Intimate Partner Violence: Recommendation Statement Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement A clinical trial of tailored office systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP). Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement Screening for Breast Cancer: Recommendations and Rationale Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement A randomized controlled trial of a community-based behavioral counseling program. Preventive Services Task Force recommends against PSA screening after age 75. Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial Sustainability of a practice-individualized preventive service delivery intervention. Screening for Depression: Recommendations and Rationale Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial Screening for Abdominal Aortic Aneurysm: US Preventive Services Task Force Recommendation Statement. Implementation of a New Screening Recommendation in Health Care: The Veterans Health Administration's Approach to Lung Cancer Screening Evaluating Test Strategies for Colorectal Cancer Screening: A Decision Analysis for the U.S. Preventive Services Task Force Reducing neuropsychiatric symptoms in persons with dementia and associated burden in family caregivers using tailored activities: Design and methods of a randomized clinical trial. Determinants of Physician Discussion Regarding Tobacco and Alcohol Abuse Two Approaches to Maternal Depression Screening During Well Child Visits Interventional Therapies, Surgery, and Interdisciplinary Rehabilitation for Low Back Pain: An Evidence-Based Clinical Practice Guideline From the American Pain Society Group Visits: Promoting Adherence to Diabetes Guidelines Preventive care for the elderly. Do family physicians comply with recommendations of the Canadian Task Force on Preventive Health Care? Assessing the STIRR model of best practices for blood-borne infections of clients with severe mental illness. Screening for Coronary Heart Disease: Recommendation Statement Routine Vitamin Supplementation To Prevent Cancer and Cardiovascular Disease: Recommendations and Rationale Statins for Primary Prevention: The Debate Is Intense, but the Data Are Weak. The effect among older persons of a general preventive visit on three health behaviors: smoking, excessive alcohol drinking, and sedentary lifestyle. The Medicare Preventive Services Research Team. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. Current Pediatrician Practices in Identifying High-risk Behaviors of Adolescents Changing physician behavior to improve disease prevention. Screening for Breast Cancer in Average-Risk Women: A Guidance Statement From the American College of Physicians Screening for cancer: advice for high-value care from the American College of Physicians. Comparative trial of a short workshop designed to enhance appropriate use of screening tests by family physicians. Training physicians to conduct physical activity counseling. Cancer prevention services and physician consensus in primary care group practices. Effects of a health promotion program on sustaining health behaviors in older adults. Improving prevention systems in primary care practices: the Health Education and Research Trial (HEART) A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer Screening and brief interventions for hazardous alcohol use in accident and emergency departments: a randomised controlled trial protocol Delivery rates for preventive services in 44 midwestern clinics. Web-based proactive system to improve breast cancer screening: a randomized controlled trial. Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial Implementing preventive services. Success and failure in an outpatient trial. Against Colorectal Cancer in Our Neighborhoods, a Community-Based Colorectal Cancer Screening Program Targeting Low-Income Hispanics The epidemic of obesity and diabetes: trends and treatments. Limitations of Basing Screening Policies on Screening Trials: The US Preventive Services Task Force and Prostate Cancer Screening Pairing Physician Education With Patient Activation to Improve Shared Decisions in Prostate Cancer Screening: A Cluster Randomized Controlled Trial
The U.S. Preventive Services Task Force ( USPSTF ) is an independent panel of experts that is convened and supported by the Agency for Healthcare Research and Quality ( AHRQ ) . The U.S. Congress has charged the USPSTF to review the scientific evidence for clinical preventive services and develop evidence -based recommendations about their delivery . In its recommendations , the USPSTF seeks to maximize population health benefits while minimizing harms . The target audience for USPSTF recommendations is primary care clinicians , but the recommendations are widely used by others as well ( 1 ) . The USPSTF processes and methods are continually examined , and recent up date s have been published ( 13 ) . The USPSTF Procedure Manual is posted on the AHRQ Web site ( 4 ) . In this issue , the USPSTF reports that it concluded that the evidence to determine whether the benefits of skin cancer screening outweigh the harms was insufficient ( 5 ) . No recommendation was made , and no letter grade was assigned . Instead , the USPSTF issued an I statement ( 2 ) . Evidence is often found to be insufficient for topics considered by the USPSTF . Even for screening topics that pertain to all or a large majority of adults , children , or adolescents , evidence is often insufficient ( Table 1 ) ( 6 ) . Table 1 . Insufficient Evidence Statements for Screening of Large Population Subgroups The release of the I statement for skin cancer screening provides an opportunity for the USPSTF to describe its plan to exp and the kinds of information it commissions to be collected and reported routinely by Evidence -based Practice Centers , to describe the process that led to selection of this information , and to illustrate the uses of the information with examples . Problem Statement Primary care physicians and their professional societies expressed frustration with the frequency with which the USPSTF concluded that evidence is insufficient to make a recommendation . In the past , the USPSTF coupled this conclusion with a recommendation worded as follows : the USPSTF concludes that the evidence is insufficient to recommend for or against routine provision of xxx service . Clinicians pointed out that this wording is not a recommendation . Anecdotally , the statement was characterized as useless and sometimes as worse than useless . In focus groups of practicing primary care providers , a common request was for USPSTF guidance on a course of action with individual patients in situations in which evidence about net benefit is insufficient . Professional society representatives reinforced the need for guidance . The USPSTF and other bodies have generally held that the strongest argument for providing an intervention is based on scientific evidence from multiple large , well-conducted , r and omized clinical trials ( RCTs ) . However , for most clinical preventive services , this st and ard of evidence is unattainable . Requirements for RCTs of behavioral counseling interventions are especially problematic because the study interventions in gold-st and ard RCTs may be artificial . Tucker and Roth ( 7 ) discuss this problem in the context of behavioral interventions for substance abuse . They point out that requiring fidelity in treatment delivery in a gold-st and ard RCT may eliminate the context ual aspects of the treatment experience and the adaptation of treatment to individual needs that underlies treatment success . Requiring a no-treatment or usual-treatment control condition may produce insurmountable barriers to recruitment . Requiring a control condition with the same number of contact hours as the treatment condition can compromise retention . For different reasons , the conduct of RCTs for preventive services delivered to infants , children , and adolescents also presents challenges . For some preventive services , the long timeline required to improve health outcomes makes RCTs impractical . Consensus is lacking about the appropriate outcomes for preventive interventions in children , although agreement is universal that decreasing mortality is not the only goal of preventive services provided to this age group . Finally , many valuable preventive interventions will never be evaluated in an RCT because a trial would be too expensive , recruiting enough participants is not feasible , or investigator interest or funding is lacking . Acknowledging the Contribution of Non- RCT Evidence and Persisting Issues Recognizing the paucity of evidence from RCTs , the USPSTF and other groups consider evidence from non- RCT study design s ( such as cohort , cross-sectional , casecontrol , or quasi-experimental ) as a st and ard strategy . Use of an analytic framework , which is an organizing principle for all recent or current USPSTF systematic review s , permits incorporation of evidence from studies with a variety of design s and yields certainty that can in theory approach the certainty of evidence derived from RCTs . In constructing an analytic framework , clinical problems are conceptualized in terms of a sequence of key questions ( 8) . A systematic review is generally done to answer each key question . When considered together , the key question evidence forms a chain of evidence that permits firm conclusions about net benefit . In the case of skin cancer , notwithst and ing the use of an analytic framework and consideration of study design s other than RCTs , the USPSTF could not conclude with even moderate certainty that the benefits of skin cancer screening by inspection outweighed the harms or that the harms outweighed the benefits , making the evidence insufficient to make a recommendation ( 9 ) . Even when non- RCT evidence is considered within a structured causal framework , the problem of insufficient evidence persists . A New Approach : Process and Outcome In response to the concerns about the frequency of I statements , the frustration expressed by clinicians , and the call for guidance , the USPSTF held a workshop in spring 2005 to consider how better to meet the needs of its constituents when evidence is insufficient . The workshop involved members of the USPSTF , AHRQ staff , and scientists from the Evidence -based Practice Center supporting the USPSTF . The charge to workshop participants was to develop a strategy that would reduce confusion created by the wording I recommendation , and to consider whether the USPSTF should nuance the Ithat is , make a suggestion in favor of or against providing the service . At the workshop , attendees heard presentations from AHRQ and Evidence -Based Practice Center staff involved in the efforts of the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) working group ( 1012 ) . Other publications about approaches to grading recommendations were identified and review ed ( 13 ) . The workshop result ed in a decision to transform what was formerly called an I recommendation into an I statement , as described elsewhere ( 2 ) . The workshop also led to a group decision to reject the proposal to nuance the I. Nuancing would have result ed in recommendations that clinicians act routinely to offer a service even in the absence of at least moderate certainty that the preventive service has net benefits at the population level , thus violating an underlying principle guiding the work of USPSTF : avoidance of overall harm . Before the workshop , attendees were charged with bringing to the meeting suggestions for criteria that might be used to nuance the I , with practice relevance for clinicians , patients , or systems as the basis for these suggestions . During the workshop , further criteria were identified by using a brainstorming technique . The product of these processes was a list of possible factors that could be used to nuance the I. After rejecting the idea of nuancing the I , the USPSTF decided to explore , after the workshop , whether provision of information about the factors identified during this process might be useful to clinicians . This follow-up work was delegated to the Methods Workgroup and members of the Evidence -based Practice Center . The follow-up group noted that almost all of the factors fell into 1 of 4 groups . The 4 information groups came to be described as domains , a term that connotes hierarchical ranking and is apt , even if accidental . That is , these information domains constitute a limited number of broadly applicable collection s of factors , considerations , or attributes pertinent to decision making about preventive services when evidence is insufficient to conclude , with certainty , that there is net benefit or net harm . After more deliberation , the Methods Workgroup proposed in 2006 that the Evidence -based Practice Center gather pertinent information in the 4 domains as part of its evidence retrieval process . The full USPSTF accepted the proposal , and members provided further input to the descriptions of the domains . The authors of this article were asked to prepare a manuscript about the process and product on behalf of the USPSTF . Domains and Rationale The first domain is potential preventable burden of suffering from the condition . When evidence is insufficient , provision of an intervention design ed to prevent a serious condition ( such as dementia ) might be viewed more favorably than provision of a service design ed to prevent a condition that does not cause as much suffering ( such as rash ) . The USPSTF recognized that burden of suffering is subjective and involves judgment . In clinical setting s , it should be informed by patient values and concerns . The second domain is potential harm of the intervention . When evidence is insufficient , an intervention with a large potential for harm ( such as major surgery ) might be viewed less favorably than an intervention with a small potential for harm ( such as advice to watch less television ) . The USPSTF again acknowledges the subjective nature and the difficulty of assessing potential harms : For example , how bad is a mild stroke ? The third domain is costnot just monetary cost , but opportunity cost , in particular the amount of time a provider spends to provide the The major goal of the U.S. Preventive Services Task Force ( USPSTF ) is to provide clinicians and policymakers with a reliable and accurate source of evidence -based recommendations on a wide range of preventive services . To accomplish this goal , the USPSTF systematic ally review s the evidence concerning both the benefits and harms of widespread implementation of a preventive service . It then assesses the certainty of the evidence and the magnitude of the benefits and harms . On the basis of this assessment , the USPSTF assigns a letter grade to each preventive service signifying its recommendation about provision of the service ( Table 1 ) . Table 1 . U.S. Preventive Services Task Force Recommendation Grid * An important , but often challenging , step is determining the balance between benefits and harms to estimate net benefit ( that is , benefits minus harms ) . In this issue , the Task Force reports an up date to its recommendation for carotid artery stenosis screening ( 1 , 2 ) . Because carotid artery stenosis screening has both known benefits and harms , estimating net benefit was critical in the final USPSTF recommendation that clinicians not provide carotid artery stenosis screening in asymptomatic people ( recommendation letter grade D ) . Release of this recommendation provides an opportunity for the Task Force to up date and explain to a clinical audience the process by which it evaluates evidence , determines the certainty and magnitude of net benefit , and gives a letter grade to the recommendation . We will do this by considering 3 questions : 1 ) What evidence does the Task Force consider to estimate net benefit ? 2 ) How does the Task Force estimate the certainty of net benefit ? and 3 ) How does the Task Force estimate the magnitude of net benefit ? What Evidence Does the Task Force Consider to Estimate Net Benefit ? The overarching question that the Task Force seeks to answer for every preventive service is whether evidence suggests that provision of the service would improve health outcomes if implemented in a general primary care population . For screening topics , this st and ard could be met by a large r and omized , controlled trial ( RCT ) in a representative asymptomatic population with follow-up of all members of both the group invited for screening and the group not invited for screening . For example , the Multicentre Aneurysm Screening Study ( 3 ) was a population -based RCT of screening for abdominal aortic aneurysm in which 67800 asymptomatic men age 65 to 74 years in the United Kingdom were r and omly assigned to be invited or not to be invited for screening . Both groups were followed for a mean of 4.1 years , and abdominal aortic aneurysmrelated mortality and all-cause mortality were compared . No RCTs of carotid artery stenosis screening have been published ; however , RCTs comparing carotid endarterectomy to medical management of asymptomatic carotid artery stenosis are available . The distinction between RCTs that r and omly assign people to undergo screening  versus RCTs that r and omly assign people known to have a condition to an intervention is important . In contrast to the latter , RCTs of screening take into account the false-positive and false-negative rates of the screening test , the possibility of adverse events from the test , the accuracy and potential for adverse events of any subsequent confirmatory diagnostic tests , and the inevitable failure to follow through on the test or any subsequent steps needed before the therapeutic intervention is delivered . In addition , conditions detected by screening may have different biological characteristics than those detected in other ways . The benefits of treating screened individuals , therefore , can not be assumed to be the same as those of treating symptomatic individuals . Screening trials directly answer a simple question important to the primary care setting : Does screening for a certain condition improve health outcomes ? Direct RCT evidence about screening is often unavailable , so the Task Force considers indirect evidence . To guide its selection of indirect evidence , the Task Force constructs a chain of evidence within an analytic framework . Figure 1 of the evidence up date ( 2 ) in this issue ( page 861 ) shows the analytic framework for the Task Force assessment of carotid artery stenosis screening . Each arrow in the framework defines a key question , and each key question represents a link in the chain of evidence . Rectangles in the framework represent the intermediate outcomes ( rounded corners ) or the health outcomes ( square corners ) ; ovals represent harms . To form an unbroken chain , evidence must support each link in the chain , thereby connecting the target population ( far left side of the framework ) to the improved health outcome ( far right side of the framework ) . For each key question , the body of pertinent literature is critically appraised , focusing on 6 questions ( Table 2 ) . The USPSTF will now describe its judgment about the evidence for each key question as convincing , adequate , or inadequate . Evidence may be considered convincing when derived from several high- quality studies with consistent , logical results that are generalizable to the U.S. primary care population and setting . Evidence may be deemed adequate when , on the basis of judgment , most but not all of these 6 questions are answered favorably . When evidence is conflicting or the studies are of poor quality individually or in aggregate , the evidence for a key question is considered inadequate . Inadequate evidence may create a critical gap in the evidence chain . Table 2 . Questions Considered by the U.S. Preventive Services Task Force for Evaluating Evidence Related Both to Key Questions and to the Overall Certainty of the Evidence of Net Benefit for the Preventive Service How Does the Task Force Estimate the Certainty of Net Benefit ? The next step in the Task Force process is to use the evidence from the key questions to assess whether there would be net benefit if the service were implemented . In 2001 , the USPSTF published an article that documented its systematic processes of evidence evaluation and recommendation development ( 4 ) . At that time , the Task Force 's overall assessment of evidence was described as good , fair , or poor . The Task Force realized that this rating seemed to apply only to how well studies were conducted and did not fully capture all of the issues that go into an overall assessment of the evidence about net benefit . To avoid confusion , the USPSTF has changed its terminology . Whereas individual study quality will continue to be characterized as good , fair , or poor , the term certainty will now be used to describe the Task Force 's assessment of the overall body of evidence about net benefit of a preventive service and the likelihood that the assessment is correct . Certainty will be determined by considering all 6 questions in Table 2 ; the judgment about certainty will be described as high , moderate , or low . In making its assessment of certainty about net benefit , the evaluation of the evidence from each key question plays a primary role . It is important to note that the Task Force makes recommendations for real-world medical practice in the United States and must determine to what extent the evidence for each key question even evidence from screening RCTs or treatment RCTs can be applied to the general primary care population . Frequently , studies are conducted in highly selected population s under special conditions . The Task Force must consider differences between the general primary care population and the population s studied in RCTs and make judgments about the likelihood of observing the same effect in actual practice . For carotid artery stenosis screening , the Task Force search ed for evidence about the true prevalence of high- grade carotid artery stenosis in the general population , the generalizability of treatment effectiveness estimates based on RCTs conducted in selected population s , and the complication rate from carotid endarterectomy in asymptomatic individuals if performed in nontrial setting s ( for example , community hospitals ) . It is also important to note that 1 of the key questions in the analytic framework refers to the potential harms of the preventive service . The Task Force considers the evidence about the benefits and harms of preventive services separately and equally . Data about harms are often obtained from observational studies because harms observed in RCTs may not be representative of those found in usual practice and because some harms are not completely measured and reported in RCTs . For example , the surgeons who enrolled patients in RCTs of carotid artery stenosis were selected on the basis of their low postoperative stroke and mortality rates . Widespread screening for carotid artery stenosis would invariably lead to surgical treatment provided in hospitals ( or by surgeons ) with higher rates of complications . The harms of screening for carotid artery stenosis , including the harms from carotid angiography to confirm the diagnosis of carotid artery stenosis in patients screening positive by carotid ultrasonography  , were not captured in some treatment RCTs . Putting the body of evidence for all key questions together as a chain , the Task Force assesses the certainty of net benefit of a preventive service by asking the 6 major questions in Table 2 . The Task Force would rate a body of convincing evidence about the benefits of a service that , for example , derives from several RCTs of screening in which the estimate of benefits can be generalized to the general primary care population as high certainty ( Table 3 ) . The Task Force would rate a body of evidence that was not clearly applicable to general practice or has other defects in quality , research design , or consistency of studies as moderate certainty . Certainty is low when , for example , there are gaps in the evidence linking parts of the analytic framework , when evidence to determine the harms of treatment is unavailable , or DESCRIPTION Up date of the 2002 U.S. Preventive Services Task Force ( USPSTF ) recommendation statement about screening for prostate cancer . METHODS The USPSTF evaluated r and omized , controlled trials of the benefits of prostate cancer screening ; cohort and cross-sectional studies of the psychological harms of false-positive prostate-specific antigen test results ; and evidence on the natural history of prostate-specific antigen-detected prostate cancer to address previously identified gaps in the evidence from the 2002 USPSTF recommendation . RECOMMENDATIONS Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years ( I statement ) . Do not screen for prostate cancer in men age 75 years or older ( Grade D recommendation ) BACKGROUND Approximately 3,000 new cases of oral cancer are diagnosed each year in Canada . Most of these cases occur among older adults with a history of tobacco use or excessive alcohol consumption . Preventive interventions for oral cancer include counselling of patients to modify risk factors and screening to identify precancerous and early-stage lesions . This report presents evidence -based guidelines on the prevention of oral cancer and precancer among asymptomatic patients . METHODS Literature search es of the 1966 - 1999 MEDLINE and CANCERLIT data bases were completed using the major MeSH heading mouth neoplasms . References from articles and recommendations of organizations were also review ed . The evidence -based methods of the Canadian Task Force on Preventive Health Care were used to assess evidence and to develop guidelines . Advice from experts and other recommendations were taken into consideration . RESULTS In cohort and case-control studies , smoking cessation decreased the risk of oral cancer and precancer . R and omized controlled trials ( RCTs ) indicate counselling by trained health care professionals is effective in promoting smoking cessation . Although counselling has been effective for the reduction of excessive alcohol consumption in RCTs , no studies have examined whether alcohol reduction reduces the risk of oral cancer or precancer . The usefulness of general population screening is limited by the low prevalence and incidence of the disease , the potential for false-positive diagnoses and the poor compliance with screening and referral . There is no evidence that screening of the general population or high-risk groups leads to a reduction in mortality or morbidity from oral cancer . INTERPRETATION There is good evidence to specifically consider smoking cessation counselling in a periodic health examination ( grade A recommendation ) . For population screening , there is fair evidence to specifically exclude screening for oral cancer ( grade D recommendation ) . For opportunistic screening during periodic examinations , there is insufficient evidence to recommend inclusion or exclusion of screening for oral cancer ( grade C recommendation ) . For patients at high risk , annual examination by physician or dentist should be considered . Risk factors include tobacco use and excessive consumption of alcohol . These recommendations are similar to those made by the Canadian Task Force on the Periodic Health Examination in 1994 and by the U.S. Preventive Services Task Force in 1996 Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) concludes that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes , impaired glucose tolerance , or impaired fasting glucose . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found good evidence that available screening tests can accurately detect type 2 diabetes during an early , asymptomatic phase . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) The USPSTF also found good evidence that intensive glycemic control in patients with clinical ly detected ( not screening detected ) diabetes can reduce the progression of microvascular disease . However , the benefits of tight glycemic control on microvascular clinical outcomes take years to become apparent . It has not been demonstrated that beginning diabetes control early as a result of screening provides an incremental benefit compared with initiating treatment after clinical diagnosis . Existing studies have not shown that tight glycemic control significantly reduces macrovascular complications , including myocardial infa rct ion and stroke . The USPSTF found poor evidence to assess possible harms of screening . As a result , the USPSTF could not determine the balance of benefits and harms of routine screening for type 2 diabetes . The USPSTF recommends screening for type 2 diabetes in adults with hypertension or hyperlipidemia . This is a grade B recommendation . The USPSTF found good evidence that , in adults who have hypertension and clinical ly detected diabetes , lowering blood pressure below conventional target blood pressure values reduces the incidence of cardiovascular events and cardiovascular mortality ; this evidence is considered fair when extrapolated to cases of diabetes detected by screening . Among patients with hyperlipidemia , there is good evidence that detecting diabetes substantially improves estimates of individual risk for coronary heart disease , which is an integral part of decisions about lipid-lowering therapy . Clinical Considerations In the absence of evidence of direct benefits of routine screening for type 2 diabetes , the decision to screen individual patients is a matter of clinical judgment . Patients at increased risk for cardiovascular disease may benefit most from screening for type 2 diabetes , since management of cardiovascular risk factors leads to reductions in major cardiovascular events . Clinicians should assist patients in making that choice . In addition , clinicians should be alert to symptoms suggestive of diabetes ( for example , polydipsia and polyuria ) and test anyone with these symptoms . Screening for diabetes in patients with hypertension or hyperlipidemia should be part of an integrated approach to reduce cardiovascular risk . Lower targets for blood pressure ( that is , diastolic blood pressure 80 mm Hg ) are beneficial for patients with diabetes and high blood pressure . The third report of the Adult Treatment Panel III of the National Cholesterol Education Program recommends lower targets for low-density lipoprotein cholesterol for patients with diabetes . Attention to other risk factors , such as physical inactivity , diet , and overweight , is also important , both to decrease risk for heart disease and to improve glucose control . Three tests have been used to screen for diabetes : fasting plasma glucose ( FPG ) , 2-hour postload plasma glucose , and hemoglobin A1c .  The American Diabetes Association ( ADA ) has recommended the FPG test for screening ( values 6.99 mmol/L [ 126 mg/dL ] indicate diabetes ) because it is easier and faster to perform , more convenient and acceptable to patients , and less expensive than other screening tests . The FPG test is more reproducible than the 2-hour plasma glucose test , has less intraindividual variation , and has similar predictive value for development of microvascular complications of diabetes . Compared with the FPG test , the 2-hour plasma glucose test may lead to more individuals being diagnosed as diabetic . Hemoglobin A1c is more closely related to FPG than to 2-hour plasma glucose , but at the usual cut-points it is less sensitive in detecting lower levels of hyperglycemia . The r and om  capillary blood glucose test has been shown to have reasonable sensitivity ( 75 % at a cut-point of 6.66 mmol/L [ 120 mg/dL ] ) in detecting persons who have an FPG level greater than or equal to 6.99 mmol/L ( 126 mg/dL ) or a 2-hour plasma glucose level greater than or equal to 11.1 mmol/L ( 200 mg/dL ) , if results are interpreted according to age and time since last meal ; however , the r and om blood glucose test is less well st and ardized for screening for diabetes . The ADA recommends confirmation of a diagnosis of diabetes with a repeated FPG test on a separate day , especially for patients with borderline FPG results and patients with normal FPG levels for whom suspicion of diabetes is high . The optimal screening interval is not known . The ADA , on the basis of expert opinion , recommends an interval of every 3 years but shorter intervals in high-risk persons . Regardless of whether the clinician and patient decide to screen for diabetes , patients should be encouraged to exercise , eat a healthy diet , and maintain a healthy weight , choices that may prevent or forestall the development of type 2 diabetes . More aggressive interventions to establish and maintain these behaviors should be considered for patients at increased risk for diabetes , such as those who are overweight , have a family history of diabetes , or have a racial or ethnic background associated with an increased risk ( for example , Native American persons ) .  Intensive programs of lifestyle modification ( diet , exercise , and behavior ) should also be considered for patients who have impaired fasting glucose or impaired glucose tolerance , since several large trials have demonstrated that these programs can significantly reduce the incidence of diabetes in these patients . Evidence and recommendations regarding counseling about diet , physical activity , and obesity are provided in the USPSTF evidence summaries Counseling to Promote a Healthy Diet , Counseling to Promote Physical Activity , and Screening and Treatment for Obesity in Adults , available on the Agency for Healthcare Research and Quality Web site at www.preventiveservices.ahrq.gov . The brief review of the evidence that is normally included in USPSTF recommendation statements is available in the complete recommendation and rationale statement on the USPSTF Web site ( www.preventiveservices.ahrq.gov ) . Recommendations of Others The ADA acknowledged that data from prospect i ve studies were insufficient to determine the benefits of diabetes screening and thus concluded that the decision to test for diabetes should be based on clinical judgment and patient preference ( 1 ) . On the basis of expert consensus , the ADA recommends clinicians consider screening for diabetes with the FPG test beginning at age 45 years and at a younger age for individuals with such risk factors as family history , overweight , and hypertension , among others . The American College of Obstetricians and Gynecologists endorses the ADA recommendations ( 2 ) . The American Heart Association recommends measuring fasting blood glucose in persons 20 years of age and older according to risk for diabetes , as part of overall risk assessment for cardiovascular disease ( 3 ) . The Canadian Task Force on Preventive Health Care is currently updating its recommendations on diabetes screening PURPOSE We determined whether the characteristics of patients undergoing prostate needle biopsies and prostate needle biopsy results changed after the U.S. Preventive Services Task Force recommendation in 2012 against prostate specific antigen based screening for prostate cancer for men of any age . MATERIAL S AND METHODS A prospect i ve data base of patients undergoing prostate needle biopsies at Virginia Mason from 2004 to 2014 was review ed . Welch 's t-test and chi-square tests were used to compare patients seen before to those seen after the USPSTF recommendation . Relative risks and corresponding confidence intervals were estimated by general linear regression . RESULTS Patients in the post-USPSTF group ( 310 ) had a higher prostate specific antigen ( p < 0.001 ) , were more likely to be diagnosed with higher clinical stage ( 2b , p=0.003 ; 2c-3a , p=0.027 ) and D'Amico high risk prostate cancer ( p=0.036 ) , with an adjusted relative risk for high risk prostate cancer of 1.25 ( 95 % CI 1.02 - 1.52 ) compared to those in the pre-USPSTF group ( 1,416 ) . Limiting the pre-USPSTF group to the 30 months before the draft guidelines ( 448 patients ) yielded similar results . The absolute number of biopsies performed decreased by 31 % , with the majority of the decrease occurring in the detection of intermediate risk tumors . CONCLUSIONS In the 2 and a half years after the USPSTF recommendation against prostate specific antigen based screening , patients undergoing prostate needle biopsies were significantly more likely to be diagnosed with high risk disease . However , a reduction in the number of prostate needle biopsies performed occurred concomitantly with a decrease in the detection of intermediate risk , potentially curable prostate cancer . Future focus on informed application of screening techniques may prevent the reversal of decades of improvement in the prostate cancer mortality rate Summary of the Recommendation The U.S. Preventive Services Task Force ( USPSTF ) found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children , of women for intimate partner violence , or of older adults or their caregivers for elder abuse . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) Appendix Table 1 . U.S. Preventive Services Task Force Recommendations and Ratings The USPSTF found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death . The USPSTF found no existing studies that determine the accuracy of screening tools for identifying family and intimate partner violence among children , women , or older adults in the general population . The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed ( see Clinical Considerations ) . The USPSTF found limited evidence as to whether interventions reduce harm to women and no studies that examined the effectiveness of interventions in older adults . No studies have directly addressed the harms of screening and interventions for family and intimate partner violence . As a result , the USPSTF could not determine the balance between the benefits and harms of screening for family and intimate partner violence among children , women , or older adults . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Appendix Table 2 . U.S. Preventive Services Task Force Strength of Overall Evidence Clinical Considerations The USPSTF did not review the evidence for the effectiveness of case-finding tools ; however , all clinicians examining children and adults should be alert to physical and behavioral signs and symptoms associated with abuse or neglect . Patients in whom abuse is suspected should receive proper documentation of the incident and physical findings ( for example , photographs , body maps ) ; treatment for physical injuries ; arrangements for skilled counseling by a mental health professional ; and the telephone numbers of local crisis centers , shelters , and protective service agencies . Victims of family violence are primarily children , female spouses/intimate partners , and older adults . Numerous risk factors for family violence have been identified , although some may be confounded by socioeconomic factors . Factors associated with child abuse or neglect include low income status , low maternal education , non-white race , large family size , young maternal age , single-parent household , parental psychiatric disturbances , and presence of a stepfather . Factors associated with intimate partner violence include young age , low income status , pregnancy , mental health problems , alcohol or substance use by victims or perpetrators , separated or divorced status , and history of childhood sexual and /or physical abuse . Factors associated with the abuse of older adults include increasing age , non-white race , low income status , functional impairment , cognitive disability , substance use , poor emotional state , low self-esteem , cohabitation , and lack of social support . Several instruments to screen parents for  child abuse have been studied , but their ability to predict child abuse or neglect is limited . Instruments to screen for intimate partner violence have also been developed , and although some have demonstrated good internal consistency ( for example , the HITS [ Hurt , Insulted , Threatened , Screamed at ] instrument , the Partner Abuse Interview , and the Women 's Experience with Battering [ WEB ] Scale ) , none have been vali date d against measurable outcomes . Only a few screening instruments ( for example , the  Caregiver Abuse Screen [ CASE ] and the HwalekSengstock Elder Abuse Screening Test  [ HSEAST ] ) have been developed to identify older potential victims of abuse or their abusive caretakers . Both of these tools correlated well with previously vali date d instruments when administered in the community but have not been tested in the primary care clinical setting ( 1 ) . Home visit programs directed at high-risk mothers ( identified on the basis of sociodemographic risk factors ) have improved developmental outcomes and decreased the incidence of child abuse and neglect , as well as decreased rates of maternal criminal activity and drug use . Discussion Approximately 1 million abused children are identified in the United States each year ( 2 ) . In 1999 , an estimated 1100 children died of abuse and neglect ( 3 ) . It is likely that reported abuse captures only a fraction of all cases . Estimates of the prevalence of intimate partner violence in the United States indicate that 1 to 4 million women are physically , sexually , or emotionally abused by their intimate partners each year ( 4 , 5 ) , with 31 % of all women reporting abuse at some point in their lifetimes ( 6 ) . Although violence by women against men also occurs , women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner ( 7 ) . The National Elder Abuse Incidence Study ( NEAIS ) estimates that approximately 551000 older adults in domestic setting s were abused and /or neglected during 1996 ( 8) . The abuse of older adults takes many forms , including physical , sexual , and psychological abuse ; financial exploitation ; and neglect ( 9 ) . In 90 % of cases , the perpetrator of such abuse is a family member , usually an adult child or spouse ( 8) . Harmful outcomes of family violence may include not only repercussions of acute trauma , including death or unwanted pregnancy , but also long-term physical problems and psychiatric disorders , such as depression , post-traumatic stress disorder , somatization , suicide , and substance abuse ( 10 - 20 ) . In addition , children who witness intimate partner violence are at risk for developmental delay ; school failure ; violent behavior ; and a variety of psychiatric disorders , including depression and oppositional defiant disorder ( 21 - 23 ) . The USPSTF focused this review on children , women , and older adults because they are the largest groups at risk for domestic violence in the general primary care setting and are most likely to have been the subjects of published studies . The USPSTF review ed the evidence for the effectiveness of screening procedures and interventions in the primary care setting in reducing harmful outcomes of domestic violence against children , women , and older adults . Because no studies were found that directly addressed the impact of screening on reducing harmful outcomes , the USPSTF examined the accuracy of clinical screening instruments in identifying risk for current or future abuse and the efficacy of clinic-based interventions in reducing harmful outcomes . Screening for child abuse in the primary care setting can involve a variety of techniques , including physical examination as well as screening question naires . Findings during a routine physical examination suggestive of abuse and /or neglect , such as burns , bruises , and repeated suspicious traumatic injury , have been described ( 24 ) . All instruments design ed to screen for child abuse and neglect were directed at parents , particularly pregnant mothers . Limited evidence suggests that these instruments had fairly high sensitivity but low specificity for identifying future child maltreatment when administered in the study population s , particularly when self-administered question naires were provided to pregnant mothers in a 2-step method , such as the Hawaii Risk Indicators Screening Tool followed by the Kempe Family Stress Inventory ( 25 , 26 ) . These question naires have not been widely tested in different population s. Newer brief instruments design ed to identify women who are victims of intimate partner violence in primary care setting s compare well with lengthier , previously vali date d instruments ( 1 ) . Studies indicate that self-administered question naires elicit more positive responses than interviewer-administered question naires in emergency department setting s ( 27 ) , but the opposite was true in a Planned Parenthood clinic ( 28 ) . No studies have evaluated the performance of screening instruments using verified outcomes of reported intimate partner abuse , although self-reported abuse may be a more accurately measured outcome than some verified outcomes ( for example , police or social services reports ) . The USPSTF found few screening instruments for the detection of older adults who are the potential victims of abuse or their caretakers . None of the instruments available have been widely vali date d. The USPSTF review ed the evidence for the efficacy of interventions with children , women , and older adults in reducing harmful outcomes of family and intimate partner violence . The intervention trials identified high-risk women and children on the basis of various inclusion criteria that have not been vali date d , including sociodemographic characteristics , maternal substance use , low infant birthweight , and homelessness . A r and omized , controlled trial with 15 years of follow-up indicated that nurse home visit programs ( for example , the NurseFamily Partnership program ) during the prenatal and 2-year postpartum periods for low-income , first-time mothers can improve the short-term and long-term outcomes of child abuse and neglect ( 29 , 30 ) . When compared with the nonintervention group , the home visit group had improved outcomes , including decreased reports of child maltreatment , child injuries/toxic ingestions and emergency department visits , and maternal criminal activity and drug use . Several trials utilizing nurse home visits for varying lengths of time and with various program components for pregnant and postpartum mothers support these findings , although the outcomes in these studies were short-term measures of child abuse and related factors ( 1 ) . There were 2 studies of interventions to decrease intimate partner violence in women ; both studies , Importance In the United States , the lifetime risk of being diagnosed with prostate cancer is approximately 13 % , and the lifetime risk of dying of prostate cancer is 2.5 % . The median age of death from prostate cancer is 80 years . Many men with prostate cancer never experience symptoms and , without screening , would never know they have the disease . African American men and men with a family history of prostate cancer have an increased risk of prostate cancer compared with other men . Objective To up date the 2012 US Preventive Services Task Force ( USPSTF ) recommendation on prostate-specific antigen (PSA)–based screening for prostate cancer . Evidence Review The USPSTF review ed the evidence on the benefits and harms of PSA-based screening for prostate cancer and subsequent treatment of screen-detected prostate cancer . The USPSTF also commissioned a review of existing decision analysis models and the overdiagnosis rate of PSA-based screening . The review s also examined the benefits and harms of PSA-based screening in patient sub population s at higher risk of prostate cancer , including older men , African American men , and men with a family history of prostate cancer . Findings Adequate evidence from r and omized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened . Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened . Potential harms of screening include frequent false-positive results and psychological harms . Harms of prostate cancer treatment include erectile dysfunction , urinary incontinence , and bowel symptoms . About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence , and 2 in 3 men will experience long-term erectile dysfunction . Adequate evidence shows that the harms of screening in men older than 70 years are at least moderate and greater than in younger men because of increased risk of false-positive results , diagnostic harms from biopsies , and harms from treatment . The USPSTF concludes with moderate certainty that the net benefit of  PSA-based screening for prostate cancer in men aged 55 to 69 years is small for some men . How each man weighs specific benefits and harms will determine whether the overall net benefit is small . The USPSTF concludes with moderate certainty that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older do not outweigh the expected harms . Conclusions and Recommendation For men aged 55 to 69 years , the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician . Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men . However , many men will experience potential harms of screening , including false-positive results that require additional testing and possible prostate biopsy ; overdiagnosis and overtreatment ; and treatment complications , such as incontinence and erectile dysfunction . In determining whether this service is appropriate in individual cases , patients and clinicians should consider the balance of benefits and harms on the basis of family history , race/ethnicity , comorbid medical conditions , patient values about the benefits and harms of screening and treatment-specific outcomes , and other health needs . Clinicians should not screen men who do not express a preference for screening . ( C recommendation ) The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older . ( D recommendation BACKGROUND The potential of primary care practice setting s to prevent disease and morbidity through health habit counseling , screening for asymptomatic disease , and immunizations has been incompletely met . This study was design ed to test a practice -tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling . DESIGN Group r and omized clinical trial and multi method process assessment . SETTING / PARTICIPANTS Seventy-seven community family practice s in northeast Ohio . INTERVENTION After a 1-day practice assessment , a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aim ed at increasing preventive service delivery . MAIN OUTCOME MEASURE Summary scores of the health habit counseling , screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during r and omly selected chart review days . RESULTS A significant increase ( p=0.015 ) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group ( 31 % to 42 % ) compared to the control group ( 35 % to 37 % ) . Rates specifically for health habit counseling ( p=0.007 ) and screening services ( p=0.048 ) were increased , but not for immunizations . CONCLUSIONS An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates The U.S. Preventive Services Task Force ( USPSTF ) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms . It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance . The USPSTF does not consider the costs of providing a service in this assessment . The USPSTF recognizes that clinical decisions involve more considerations than evidence alone . Clinicians should underst and the evidence but individualize decision making to the specific patient or situation . Similarly , the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms . Summary of Recommendation and Evidence The USPSTF recommends annual screening for lung cancer with low-dose computed tomography ( LDCT ) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years . Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery . ( B recommendation ) See the Clinical Considerations section for suggestions for implementation in practice . See the Figure for a summary of the recommendation and suggestions for clinical practice . Figure . Screening for lung cancer : clinical summary of U.S. Preventive Services Task Force recommendation . Appendix Table 1 describes the USPSTF grade s , and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit . Appendix Table 1 . What the USPSTF Grade s Mean and Suggestions for Practice Appendix Table 2 . USPSTF Levels of Certainty Regarding Net Benefit Supplement . Consumer Fact Sheet . Rationale Importance Lung cancer is the third most common cancer and the leading cause of cancer-related death in the United States ( 1 ) . The most important risk factor for lung cancer is smoking , which results in approximately 85 % of all U.S. lung cancer cases ( 2 ) . Although the prevalence of smoking has decreased , approximately 37 % of U.S. adults are current or former smokers ( 2 ) . The incidence of lung cancer increases with age and occurs most commonly in persons aged 55 years or older . Increasing age and cumulative exposure to tobacco smoke are the 2 most common risk factors for lung cancer . Lung cancer has a poor prognosis , and nearly 90 % of persons with lung cancer die of the disease . However , early-stage nonsmall cell lung cancer ( NSCLC ) has a better prognosis and can be treated with surgical resection . Detection Most lung cancer cases are NSCLC , and most screening programs focus on the detection and treatment of early-stage NSCLC . Although chest radiography and sputum cytologic evaluation have been used to screen for lung cancer , LDCT has greater sensitivity for detecting early-stage cancer ( 3 ) . Benefits of Detection and Early Treatment Although lung cancer screening is not an alternative to smoking cessation , the USPSTF found adequate evidence that annual screening for lung cancer with LDCT  in a defined population of high-risk persons can prevent a substantial number of lung cancerrelated deaths . Direct evidence from a large , well-conducted , r and omized , controlled trial ( RCT ) provides moderate certainty of the benefit of lung cancer screening with LDCT in this population ( 4 ) . The magnitude of benefit to the person depends on that person 's risk for lung cancer because those who are at highest risk are most likely to benefit . Screening can not prevent most lung cancerrelated deaths , and smoking cessation remains essential . Harms of Detection and Early Intervention and Treatment The harms associated with LDCT screening include false-negative and false-positive results , incidental findings , overdiagnosis , and radiation exposure . False-positive LDCT results occur in a substantial proportion of screened persons ; 95 % of all positive results do not lead to a diagnosis of cancer . In a high- quality screening program , further imaging can resolve most false-positive results ; however , some patients may require invasive procedures . The USPSTF found insufficient evidence on the harms associated with incidental findings . Overdiagnosis of lung cancer occurs , but its precise magnitude is uncertain . A modeling study performed for the USPSTF estimated that 10 % to 12 % of screen-detected cancer cases are overdiagnosedthat is , they would not have been detected in the patient 's lifetime without screening . Radiation harms , including cancer result ing from cumulative exposure to radiation , 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 . USPSTF Assessment The USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age , total cumulative exposure to tobacco smoke , and years since quitting smoking . The 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 ( National Lung Screening Trial ) , and the resolution of most false-positive results without invasive procedures ( 4 ) . Clinical Considerations Patient Population Under Consideration The risk for lung cancer increases with age and cumulative exposure to tobacco smoke and decreases with time since quitting smoking . The best evidence for the benefit of screening comes from the NLST , which enrolled adults aged 55 to 74 years who had at least a 30 pack-year smoking history and were current smokers or had quit within the past 15 years . As with all screening trials , the NLST tested a specific intervention over a finite period . Because initial eligibility extended through age 74 years and participants received 3 annual screening computed tomographic scans  , the oldest participants in the trial were aged 77 years . The USPSTF used modeling studies to predict the benefits and harms of screening programs that use different screening intervals , age ranges , smoking histories , and times since quitting . A program that annually screens adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years is projected to have a reasonable balance of benefits and harms . The model assumes that persons who achieve 15 years of smoking cessation during the screening program discontinue screening . This model predicts the outcomes of continuing the screening program used in the NLST through age 80 years . Screening may not be appropriate for patients with substantial comorbid conditions , particularly those at 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 . The baseline characteristics of the NLST showed a relatively healthy sample , and fewer than 10 % of enrolled participants were older than 70 years ( 5 ) . Persons with serious comorbid conditions may experience net harm , no net benefit , or at least substantially less net benefit . Similarly , persons who are unwilling to have curative lung surgery are unlikely to benefit from a screening program . Assessment of Risk Age , total exposure to tobacco smoke , and years since quitting smoking are important risk factors for lung cancer and were used to determine eligibility in the NLST . Other risk factors include specific occupational exposures , radon exposure , family history , and history of pulmonary fibrosis or chronic obstructive lung disease . The incidence of lung cancer is relatively low in persons younger than 50 years but increases with age , especially after age 60 years . In current and former smokers , age-specific incidence rates increase with age and cumulative exposure to tobacco smoke . Smoking cessation substantially reduces a person 's risk for developing and dying of lung cancer . Among persons enrolled in the NLST , those who were at highest risk because of additional risk factors or a greater cumulative exposure to tobacco smoke experienced most of the benefit ( 6 ) . A vali date d multivariate model showed that persons in the highest 60 % of risk accounted for 88 % of all deaths preventable by screening . Screening Tests Low-dose computed tomography has shown high sensitivity and acceptable specificity for the detection of lung cancer in high-risk persons .  Chest radiography and sputum cytologic evaluation  have not shown adequate sensitivity or specificity as screening tests . Therefore , LDCT is currently the only recommended screening test for lung cancer . Treatment Surgical resection is the current st and ard of care for localized NSCLC . This type of cancer is treated with surgical resection when possible and also with radiation and chemotherapy . Annual LDCT screening may not be useful for patients with life-limiting comorbid conditions or poor functional status who may not be c and i date s for surgery . Other Approaches to Prevention Smoking cessation is the most important intervention to prevent NSCLC . Advising smokers to stop smoking and preventing nonsmokers from being exposed to tobacco smoke are the most effective ways to decrease the morbidity and mortality associated with lung cancer . Current smokers should be informed of their continuing risk for lung cancer and offered cessation treatments . Screening with LDCT should be viewed as an adjunct to tobacco cessation interventions . Useful Re sources Clinicians have many re sources to help patients stop smoking . The Centers for Disease Control and Prevention has developed a Web site with many such re sources , including information on tobacco quit lines , available in several language s ( www.cdc.gov/tobacco/campaign/tips ) . Quit Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends screening mammography , with or without clinical breast examination ( CBE ) , every 1 to 2 years for women aged 40 and older . This is a grade B recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found fair evidence that mammography screening every 12 to 33 months significantly reduces mortality from breast cancer . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Evidence is strongest for women aged 50 to 69 , the age group generally included in screening trials . For women aged 40 to 49 , the evidence that screening mammography reduces mortality from breast cancer is weaker , and the absolute benefit of mammography is smaller , than it is for older women . Most , but not all , studies indicate a mortality benefit for women undergoing mammography at ages 40 to 49 , but the delay in observed benefit in women younger than 50 makes it difficult to determine the incremental benefit of beginning screening at age 40 rather than at age 50 . The absolute benefit is smaller because the incidence of breast cancer is lower among women in their 40s than it is among older women . The USPSTF concluded that the evidence is also generalizable to women aged 70 and older ( who face a higher absolute risk of breast cancer ) if their life expectancy is not compromised by comorbid disease . The absolute probability of benefits of regular mammography  increases along a continuum with age , whereas the likelihood of harms from screening ( false-positive results and unnecessary anxiety , biopsies , and cost ) diminishes from ages 40 to 70 . The balance of benefits and potential harms , therefore , grows more favorable as women age . The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice . The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40 to 49 ( see Clinical Considerations ) . The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer . This is a grade I recommendation . No screening trial has examined the benefits of CBE alone ( without accompanying mammography ) compared to no screening , and design characteristics limit the generalizability of studies that have examined CBE . The USPSTF could not determine the benefits of CBE alone or the incremental benefit of adding CBE to mammography . The USPSTF therefore could not determine whether potential benefits of routine CBE outweigh the potential harms . The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination ( BSE ) . This is a grade I recommendation . The USPSTF found poor evidence to determine whether BSE reduces breast cancer mortality . The USPSTF found fair evidence that BSE is associated with an increased risk of false-positive results and biopsies . Because of design limitations of published and ongoing studies of BSE , the USPSTF could not determine the balance of benefits and potential harms of BSE . Clinical Considerations The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences . Clinicians should inform women about the potential benefits ( reduced chance of dying from breast cancer ) , potential harms ( for example , false-positive results , unnecessary biopsies ) , and limitations of the test that apply to women their age . Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70 . Women who are at increased risk for breast cancer ( for example , those with a family history of breast cancer in a mother or sister , a previous breast biopsy revealing atypical hyperplasia , or first childbirth after age 30 ) are more likely to benefit from regular mammography than women at lower risk . The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause . The USPSTF did not examine whether women should be screened for genetic mutations ( BRCA1 and BRCA2 ) that increase the risk of developing breast cancer , or whether women with genetic mutations might benefit from earlier or more frequent screening for breast cancer . In the trials that demonstrated the effectiveness of mammography in lowering breast cancer mortality , screening was performed every 12 to 33 months . For women aged 50 and older , there is little evidence to suggest that annual mammography is more effective than mammography done every other year . For women aged 40 to 49 , available trials also have not reported a clear advantage of annual mammography over biennial mammography . Nevertheless , some experts recommend annual mammography based on the lower sensitivity of the test and on evidence that tumors grow more rapidly in this age group . The precise age at which to discontinue screening mammography is uncertain . Only two r and omized , controlled trials enrolled women older than 69 , and no trials enrolled women older than 74 . Older women face a higher probability of developing and dying of breast cancer but also have a greater chance of dying of other causes . Women with comorbid conditions that limit their life expectancy are unlikely to benefit from screening . Clinicians should refer patients to  mammography screening centers with proper accreditation and quality assurance st and ards to ensure accurate imaging and radiographic interpretation . Clinicians should adopt office systems to ensure timely and adequate follow-up of abnormal results . A listing of accredited facilities is available at www . fda .gov/cdrh/mammography/certified.html . Clinicians who advise women to perform BSE or who perform routine CBE to screen for breast cancer should underst and that there is currently insufficient evidence to determine whether these practice s affect breast cancer mortality and that they are likely to increase the incidence of clinical assessment s and biopsies . The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation and rationale statement on the USPSTF Web site ( www.preventiveservices.ahrq.gov ) . Recommendations of Others Nearly all North American organizations support mammography screening , although groups vary in the recommended age to begin screening , the interval for screening , and the role of CBE . The American Medical Association ( AMA ) ( 1 ) , the American College of Radiology ( ACR ) ( 2 ) , and the American Cancer Society ( ACS ) ( 3 ) all support screening with mammography and CBE beginning at age 40 . The American College of Obstetricians and Gynecologists ( ACOG ) ( 4 ) supports screening with mammography beginning at age 40 and CBE beginning at age 19 . The Canadian Task Force on Preventive Health Care ( CTFPHC ) ( 5 ) , the American Academy of Family Physicians ( AAFP ) ( 6 ) , and the American College of Preventive Medicine ( ACPM ) ( 7 ) recommend beginning mammography for average-risk women at age 50 . The AAFP and ACPM recommend that mammography in high-risk women begin at age 40 , and the AAFP recommends that all women aged 40 to 49 be counseled about the risks and benefits of mammography before making decisions about screening ( 6 , 7 ) . A 1997 Consensus Development Panel convened by the U.S. National Institutes of Health concluded that the evidence was insufficient to determine the benefits of mammography among women aged 40 to 49 . This panel recommended that women aged 40 to 49 should be counseled about potential benefits and harms before making decisions about mammography ( 8) . In 2001 , the CTFPHC concluded there was insufficient evidence to recommend for or against mammography in women 40 to 49 ( 9 ) . Organizations differ on their recommendations for the appropriate interval for mammography .  Annual mammography is recommended by the AMA , ACR , and ACS ( 1 - 3 ) . Mammography every 1 to 2 years is recommended by the CTFPHC , AAFP , and ACPM ( 5 - 7 ) . The ACOG recommends mammography every 1 to 2 years for women aged 40 to 49 and annually for women aged 50 and older ( 4 ) . In its 2001 report , the CTFPHC recommends against teaching  BSE  to women aged 40 to 69 ( 10 ) . The AMA , ACS , ACOG , and AAFP support teaching BSE ( 1 , 3 , 4 , 6 ) The U.S. Preventive Services Task Force ( USPSTF ) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms . It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance . The USPSTF does not consider the costs of providing a service in this assessment . The USPSTF recognizes that clinical decisions involve more considerations than evidence alone . Clinicians should underst and the evidence but individualize decision making to the specific patient or situation . Similarly , the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms . Summary of Recommendations and Evidence The USPSTF recommends biennial screening mammography for women aged 50 to 74 years . ( B recommendation ) The decision to start screening  mammography  in women prior to age 50 years should be an individual one . Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years . ( C recommendation ) 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 . Of all of the age groups , 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 . In addition to false-positive results and unnecessary biopsies , 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 ( known as overdiagnosis ) . Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment . 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 . Go to the Clinical Considerations section for information on implementation of the C recommendation . The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older . ( I statement ) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomo synthesis ( DBT ) as a primary screening method for breast cancer . ( I statement ) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography , magnetic resonance imaging ( MRI ) , DBT , or other methods in women identified to have dense breasts on an otherwise negative screening mammogram . ( I statement ) These recommendations apply to asymptomatic women aged 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation ( such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome ) or a history of chest radiation at a young age . See Figure 1 for a summary of the recommendation and suggestions for clinical practice . Figure 1 . Screening for breast cancer : clinical summary . Appendix Table 1 describes the USPSTF grade s , and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit . Appendix Table 1 . What the USPSTF Grade s Mean and Suggestions for Practice Appendix Table 2 . USPSTF Levels of Certainty Regarding Net Benefit Supplement . Consumer Fact Sheet Rationale Importance Breast cancer is the second-leading cause of cancer death among women in the United States . In 2015 , an estimated 232000 women were diagnosed with the disease and 40000 women died of it . It is most frequently diagnosed among women aged 55 to 64 years , and the median age of death from breast cancer is 68 years ( 1 ) . Benefit and Harms of Screening and Early Treatment The USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women aged 40 to 74 years . The number of breast cancer deaths averted increases with age ; women aged 40 to 49 years benefit the least and women aged 60 to 69 years benefit the most . Age is the most important risk factor for breast cancer , and the increased benefit observed with age is at least partly due to the increase in risk . Women aged 40 to 49 years who have a first-degree relative with breast cancer have a risk for breast cancer similar to that of women aged 50 to 59 years without a family history . Direct evidence about the benefits of screening mammography in women aged 75 years or older is lacking . The USPSTF found adequate evidence that screening for breast cancer with mammography results in harms for women aged 40 to 74 years . The most important harm is the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to a woman 's health , or even apparent , during her lifetime ( that is , overdiagnosis and overtreatment ) . False-positive results are common and lead to unnecessary and sometimes invasive follow-up testing , with the potential for psychological harms ( such as anxiety ) . False-negative results ( that is , missed cancer ) also occur and may provide false reassurance . Radiation-induced breast cancer and result ing death can also occur , although the number of both of these events is predicted to be low . The USPSTF found inadequate evidence on the benefits and harms of DBT as a primary screening method for breast cancer . Similarly , the USPSTF found inadequate evidence on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography , MRI , DBT , or other methods in women identified to have dense breasts on an otherwise negative screening mammogram . In both cases , while there is some information about the accuracy of these methods , there is no information on the effects of their use on health outcomes , such as breast cancer incidence , mortality , or overdiagnosis rates . USPSTF Assessment The USPSTF concludes with moderate certainty that the net benefit of screening  mammography  in women aged 50 to 74 years is moderate . The USPSTF concludes with moderate certainty that the net benefit of  screening mammography  in the general population of women aged 40 to 49 years , while positive , is small . The USPSTF concludes that the evidence on  mammography screening  in women age 75 years and older is insufficient , and the balance of benefits and harms can not be determined . The USPSTF concludes that the evidence on DBT as a primary screening method for breast cancer is insufficient , and the balance of benefits and harms can not be determined . The USPSTF concludes that the evidence on adjunctive screening for breast cancer using breast ultrasound , MRI , DBT , or other methods in women identified to have dense breasts on an otherwise negative screening mammogram is insufficient , and the balance of benefits and harms can not be determined . Clinical Considerations Benefit of Screening The results of the meta- analysis of clinical trials from the systematic evidence review commissioned by the USPSTF are summarized in Table 1 . Over a 10-year period , screening 10000 women aged 60 to 69 years will result in 21 ( 95 % CI , 11 to 32 ) fewer breast cancer deaths . The benefit is smaller in younger women : Screening 10000 women aged 50 to 59 years will result in 8 ( CI , 2 to 17 ) fewer breast cancer deaths , and screening 10000 women aged 40 to 49 years will result in 3 ( CI , 0 to 9 ) fewer breast cancer deaths ( 2 , 3 ) . Most of these trials began enrollment more than 30 years ago , and these estimates may not reflect the current likelihood of avoiding a breast cancer death with contemporary screening mammography technology . Mammography imaging has since improved , which may result in more tumors being detected at a curable stage today than at the time of these trials . However , breast cancer treatments have also improved , and as treatment improves , the advantage of earlier detection decreases , so that some of the women who died of breast cancer in the nonscreened groups in these trials would survive today . Table 1 . Breast Cancer Deaths Avoided ( 95 % CI ) per 10 000 Women Screened by Repeat Screening Mammography Over 10 Years : Data From R and omized , Controlled Trials * Harms of Screening The most important harm of screening is the detection and treatment of invasive and noninvasive cancer that would never have been detected , or threaten health , in the absence of screening ( overdiagnosis and overtreatment ) . Existing science does not allow for the ability to determine precisely what proportion of cancer diagnosed by mammography today reflects overdiagnosis , and estimates vary widely depending on the data source and method of calculation used ( 2 , 4 ) . In the United States , the rate of diagnosis of invasive plus noninvasive breast cancer increased by 50 % during the era of mammography screening ( Figure 2 ) ( 5 ) . It is not possible to know with certainty what proportion of that increase is due to overdiagnosis and what proportion reflects other reasons for a rising incidence . If overdiagnosis is the only explanation for the increase , 1 in 3 women diagnosed with breast cancer today is being treated for cancer that would never have been discovered or caused her health problems in the absence of screening . The best estimates from r and omized , controlled trials ( RCTs ) evaluating BACKGROUND The US Preventive Services Task Force ( USPSTF ) recommends that clinicians refer obese adults for intensive , multicomponent behavioral counseling , yet most obese Americans choose a self-help approach to lose weight . The current study examined weight loss between a community-based , intensive behavioral counseling program ( Weight Watchers program ) and a self-help condition . METHODS A total of 292 participants were r and omized to either a Weight Watchers condition ( WW ) ( n = 147 ) or a self-help condition ( n = 145 ) . Participants in the WW condition were provided with 3 ways to access the treatment : weekly meetings ; WW mobile application ; and WW online tools .  Weights were measured at baseline and at 3 and 6 months . Additionally , self-report use of access modes was collected at 3 and 6 months . RESULTS Participants in the WW condition significantly decreased their body mass index at 6 months ( F = 36.7 , P < .001 ) and were 8.0 and 8.8 times more likely to achieve a 5 % and 10 % reduction in weight , respectively , compared with those in the self-help condition . In a secondary analysis , high usage of all 3 access modes result ed in the greatest weight loss ( P < .001 ) . CONCLUSION Use of the WW program yielded significantly greater weight loss than a self-help approach , suggesting it is a viable community-based provider of weight loss treatment , as recommended by the USPSTF . Further , high usage of 3 access modes was associated with greater weight loss results For years , physicians and their patients have decided , on an individual basis , whether or not to use a prostate-specific antigen ( PSA ) screening test , which can detect not only life-threatening prostate cancer but also many cancers that may never pose a danger . No clear evidence exists for whether the test provides more benefit or harm , given the aggressive treatments that often follow a positive cancer diagnosis , and so patients and physicians face a difficult choice about whether to use the test . Without definitive data , the U.S. Preventive Services Task Force ( USPSTF ) , part of the federal Agency for Healthcare Research and Quality , issued guidelines in 1996 and again in 2002 that said it can not recommend for or against PSA testing . Many other organizations that provide guidance to physicians ordering PSA tests — such as the American Cancer Society , the American College of Physicians , and the American Academy of Family Physicians (AAFP)—also adopted this position . Despite the lack of evidence , the PSA test became popular , especially for older men . In 2006 , more than 58 % of men aged 50–59 years had a PSA test within the past 2 years , according to prevalence data compiled by the U.S. Centers for Disease Control and Prevention . Older men used the test much more often . The Centers for Disease Control reported that 72 % of men aged 60–64 years had had a PSA test , and for men aged 65 years and older , it was almost 77 % . PSA testing has also led to unprecedented rates of treatment for prostate cancer : More than 90 % of men diagnosed with the disease receive some form of treatment , even though many research ers believe that most prostate cancer cases will never become a health issue . Only about one-sixth of patients diagnosed with prostate cancer ultimately succumb to the disease , but there is no way currently to identify which prostate cancers should be treated aggressively . Now , citing new findings , the USPSTF has recommended that men aged 75 years and older not be screened with the PSA test , and it reiterates that the benefits of the test are still unproven in younger ages . The USPSTF laid out its recommendations in the August 5 issue of the Annals of Internal Medicine , saying that men who have a life expectancy of 10 or fewer years would suffer more immediate harm than long-term benefit from the consequences of a PSA screening test . U.S. population figures show that most men do n't live beyond age 85 . About 71 % of deaths from prostate cancer occurred in men older than 75 years . And because dying from prostate cancer once it is diagnosed often takes at least a decade , men this age will probably die from other causes before the cancer kills them . Therefore , task force members say age 75 years should be the cutoff for prostate cancer screening . But some physicians predict that the USPSTF 's revised guideline will generally be ignored — particularly by urologists — for a variety of reasons , including fears of age discrimination , ingrained medical practice , and health care economics . The new guidelines are “ underst and able and reasonable ” when one considers that there are no r and omized clinical trials that have yet demonstrated a mortality benefit to men who were screened with PSA or digital rectal exams at any age , said Peter Scardino , M.D. , chairman of the department of surgery at Memorial Sloan-Kettering Cancer Center . “ From a public health point of view , screening has not been proven . But what makes sense in theory may not in practice , ” Scardino said . “ If an older man comes in and says he wants a PSA test , I think any doctor will agree to it . ” “ The USPSTF guidelines , for the most part , have been received with indifference by the clinical community , in my opinion , ” said David Penson , M.D. , a urologist at the University of Southern California . Establishing an age-specific cutoff time is “ arbitrary and unfair and might deny men a potentially beneficial intervention , ” he said . In any case , “ the proverbial cat is out of the bag , ” Penson said . “ One of the biggest issues that clinicians face is that patients dem and prostate cancer screening , regardless of their age . It is difficult to convince patients otherwise , even if it is absolutely clear that they will not benefit from screening . Background To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting . Methods A prospect i ve cluster r and omized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto .  Preventive Care Checklist Forms © were created to be used by family physicians at adult health check-ups over a five-month period . The sex-specific forms incorporate evidence -based recommendations on preventive health services and documentation space for routine procedures such as physical examination . The forms were used in two intervention clinics and two control clinics . Rates and relative risks ( RR ) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to- date preventive health services delivered per patient were compared between the two groups . Results R and omly-selected charts were review ed at baseline ( n = 509 ) and post-intervention ( n = 608 ) . Baseline rates for provision of preventive health services ranged from 3 % ( fecal occult blood testing ) to 93 % ( blood pressure measurement ) , similar to other setting s. The percentage of up-to- date preventive health services delivered per patient at the end of the intervention was 48.9 % in the control group and 71.7 % in the intervention group . This is an overall 22.8 % absolute increase ( p = 0.0001 ) , and 46.6 % relative increase in the delivery of preventive health services per patient in the intervention group compared to controls . Eight of thirteen preventive health services showed a statistically significant change ( p < 0.05 ) in favor of the intervention ( adjusted RR ( 95 % C.I. ) ) :  counseling on brushing/flossing teeth  ( 9.2 ( 4.3–19.6 ) ) ,  folic acid counseling  ( 7.5 ( 2.7–20.8 ) ) , fecal occult blood testing ( 6.7 ( 1.9–24.1 ) ) , smoking cessation counseling ( 3.9 ( 2.2–7.2 ) ) , tetanus immunization ( 3.0 ( 1.7–5.2 ) ) , history of alcohol intake ( 1.33 ( 1.2–1.5 ) ) , history of smoking habits ( 1.28 ( 1.2–1.4 ) ) and blood pressure measurement ( 1.05 ( 1.00–1.10 ) ) . Conclusion This simple , low cost , clinical ly relevant intervention improves the delivery of preventive health services by prompting physicians of evidence -based recommendations in a checklist format that incorporates existing practice patterns . Periodic up date s of the Preventive Care Checklist Forms © will allow a feasible and easy-to-use tool for primary care physicians to provide evidence -based preventive health services to adults at routine health check-ups . The forms can also be incorporated into an electronic health record . The Preventive Care Checklist Forms © are accessible in English and French at the College of Family Physicians of Canada web site BACKGROUND The long-term effect of most interventions has not been studied . Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends . This analysis reports the 24-month follow-up of a practice -tailored intervention to increase preventive service delivery rates . DESIGN Group r and omized clinical trial with 24-month follow-up of intervention sites . SETTING / PARTICIPANTS Seventy-seven community family practice s in northeast Ohio . INTERVENTION Practice -individualized facilitation of implementation of tools and approaches . MAIN OUTCOME MEASURES Summary scores of health habit counseling , screening , and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during r and omly selected chart review days . RESULTS Previously reported increases in global preventive service delivery rates , health habit counseling , and screening rates at 12 months were sustained after 24 months . CONCLUSIONS A practice -individualized approach can result in sustainable increases in rates of preventive service delivery , even 1 year after the outside intervention stimulus ends . Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends screening adults for depression in clinical practice s that have systems in place to assure accurate diagnosis , effective treatment , and follow-up . This is a grade B recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) Appendix Table 1 . U.S. Preventive Services Task Force Grade s and Recommendations The USPSTF found good evidence that screening improves the accurate identification of depressed patients in primary care setting s and that treatment of depressed adults identified in primary care setting s decreases clinical morbidity . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Trials that have directly evaluated the effect of screening on clinical outcomes have shown mixed results . Small benefits have been observed in studies that simply feed back screening results to clinicians . Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective follow-up and treatment . The USPSTF concluded the benefits of screening are likely to outweigh any potential harms . Appendix Table 2 . U.S. Preventive Services Task Force Grade s for Strength of Overall Evidence The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression . This is a grade I recommendation . The USPSTF found limited evidence on the accuracy and reliability of screening tests in children and adolescents and limited evidence on the effectiveness of therapy in children and adolescents identified in primary care setting s. Clinical Considerations Many formal screening tools are available ( for example , the Zung Self-Depression Scale , Beck Depression Inventory , General Health Question naire , and Center for Epidemiologic Study Depression Scale ) ( 1 , 2 ) . Asking two simple questions about mood and anhedonia ( Over the past 2 weeks , have you felt down , depressed , or hopeless ? and Over the past 2 weeks , have you felt little interest or pleasure in doing things ? ) may be as effective as using longer instruments ( 3 ) . There is little evidence to recommend one screening method over another , so clinicians can choose the method that best fits their personal preference , the patient population served , and the practice setting . All positive screening tests should trigger full diagnostic interviews that use st and ard diagnostic criteria ( for example , those from the fourth edition of Diagnostic and Statistical Manual of Mental Disorders ) to determine the presence or absence of specific depressive disorders , such as major depression or dysthymia ( 4 ) . The severity of depression and comorbid psychological problems ( for example , anxiety , panic attacks , or substance abuse ) should be addressed . Many risk factors for depression ( such as female sex , family history of depression , unemployment , and chronic disease ) are common , but the presence of risk factors alone can not distinguish depressed from nondepressed patients . The optimal interval for screening is unknown . Recurrent screening may be most productive in patients with a history of depression , unexplained somatic symptoms , comorbid psychological conditions ( such as panic disorder or generalized anxiety ) , substance abuse , or chronic pain . Clinical practice s that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis , effective treatment , and careful follow-up . Benefits from screening are unlikely to be realized unless such systems are functioning well . Treatment may include antidepressants or specific psychotherapeutic approaches ( for example , cognitivebehavioral therapy or brief psychosocial counseling ) , alone or in combination . The benefits of routinely screening children and adolescents for depression are not known . The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective , but the clinical impact of routine depression screening has not been studied in pediatric population s in primary care setting s. Clinicians should remain alert for possible signs of depression in younger patients . The predictive value of positive screening tests is lower in children and adolescents than in adults , and research on the effectiveness of primary carebased interventions for depression in this age group is limited . Scientific Evidence Epidemiology and Clinical Consequences Depressive disorders are common , chronic , and costly . The World Health Organization identified major depression as the fourth leading cause of worldwide disease in 1990 , causing more disability than either ischemic heart disease or cerebrovascular disease ( 5 ) . In primary care setting s , the point prevalence of major depression ranges from 5 % to 9 % among adults , and up to 50 % of depressed patients are not recognized ( 6 , 7 ) . Other disabling depressive illnesses include dysthymia ( a chronic low- grade depression ) and minor depression ( an episodic , less severe illness ) . These two illnesses are as common as major depression in primary care setting s.  Depressive disorders  are also relatively common in younger persons , with estimated prevalences of 0.8 % to 2.0 % in children and 4.5 % in adolescents . Accuracy and Reliability of Screening Tests Several depression screening instruments are available ; most instruments have relatively good sensitivity ( 80 % to 90 % ) but only fair specificity ( 70 % to 85 % ) ( 2 ) . Most instruments are easy to use and can be administered in less than 5 minutes . Shorter screening tests , including simply asking questions about depressed mood and anhedonia , appear to detect a majority of depressed patients and , in some cases , perform better than the original instrument from which they were derived ( 3 ) . Assuming optimal test performance and a prevalence of major depression of 5 % to 10 % in primary care setting s , about 24 % to 40 % of patients who screen positive will have major depression . Some patients with false-positive results on screening may have dysthymia or subsyndromal depressive disorders that might benefit from treatment or closer monitoring ; others may have comorbid disorders such as anxiety disorder , substance abuse , panic disorder , post-traumatic stress disorder , or grief reactions ; still others may have no disorder at all . The finding of a positive screen therefore requires further diagnostic question ing by the clinician to establish an appropriate diagnosis and initiate a plan for treatment and follow-up . Screening instruments have been tested in children and adolescents , with sensitivity ranging from 40 % to 100 % and specificity from 49 % to 100 % . Because the underlying prevalence is much lower than in adults , the positive predictive value is low . Effectiveness of Early Treatment Effective treatments are available for patients with depressive illnesses detected in primary care setting s ( 1 , 8) . Antidepressant medications for major depression , including tricyclic antidepressants and selective serotonin reuptake inhibitors , are clearly more effective than placebo . Most of the data supporting effectiveness come from structured trials with selected population s , although more recent studies using usual care comparison groups and real-world setting s have produced similar effects . Newer agents perform similarly to older agents . Psychosocial and psychotherapeutic interventions are probably as effective as antidepressant medications for major depression , but they are clearly more time-intensive ( 7 ) . The benefits of psychotherapy for other depressive illnesses are less well studied . Few studies have examined the effect of combining medications and psychotherapy . No studies have examined treatment outcomes for  children or adolescents  identified by primary care clinicians through screening . Evidence for treating adolescents comes from school and community setting s where selective serotonin reuptake inhibitors and cognitivebehavioral therapy , but not tricyclic antidepressants , appear to be effective . Whether these results can be generalized to primary care setting s or to children is unclear . Effectiveness of Screening The review for the USPSTF identified 14 r and omized , controlled trials that have examined the effectiveness of screening for depression in primary care setting s ( 9 ) . In 8 studies , the only intervention was feedback of screening results to clinicians ; remaining studies combined feedback with other interventions for patients or clinicians . The trials reported various outcomes , including recognition of depression , rates of treatment , and clinical improvement among patients with depression . In 7 trials , routine depression screening with feedback of screening results to providers generally increased recognition of depression , especially major depression , by a factor of two to three compared with usual care . Trials that examined the effect of feedback of screening results on the proportion of depressed patients who received treatment showed mixed results : In 4 fair- to good- quality trials that used feedback alone , there was no significant effect on treatment rates , but 4 of the 5 trials that combined feedback with treatment advice or other system supports reported increased treatment rates in the intervention group compared with usual care . Ten trials measured the effect of  screening and feedback on depression outcomes from 1 month to 2 years after the intervention . Five of these 10 studies reported significant improvements in the clinical outcomes of depressed patients , and 3 others reported improvements that did not reach statistical significance . All three trials that compared the effects of integrated recognition and management programs with usual care in community primary care practice s showed significantly improved patient outcomes . Integrated programs included feedback , provider or patient education , access to When the GUIDE TO COMMUNITY PREVENTIVE SERVICES :  Systematic Review s and Evidence -Based Recommendations ( the Guide ) is published in 2001 , it will represent a significant national effort in encouraging evidence -based public health practice in defined population s ( e.g. , communities or members of specific managed care plans ) . The Guide will make recommendations regarding public health interventions to reduce illness , disability , premature death , and environmental hazards that impair community health and quality of life . The Guide is being developed under the guidance of the Task Force on Community Preventive Services ( the Task Force)-a 15-member , nonfederal , independent panel of experts . Subject matter experts , method ologists , and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature review s of evidence of effectiveness , economic efficiency , and feasibility on which to base recommendations for community action . Contributors to the Guide are building on the experience of others to confront method ologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonr and omized design s and diverse measures of outcome and effectiveness . Persons who plan , fund , and implement population -based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors . When the Guide is complete , readers are encouraged to consider critically the value and relevance of its contents , the implementation of interventions the Task Force recommends , the ab and onment of interventions the Task Force does not recommend , and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness Background Unhealthy alcohol use is a major contributor to the global burden of disease and injury . The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical setting s since 2004 . Yet less than one in six US adults report health care professionals discussing alcohol with them . Little is known about methods for increasing implementation ; different staffing models may be related to implementation effectiveness . This implementation trial compared delivery of alcohol screening , brief intervention and referral to specialty treatment ( SBIRT ) by physicians versus non-physician providers receiving training , technical assistance , and feedback reports . Methods The study was a cluster r and omized implementation trial ( ADVISe [ Alcohol Drinking as a Vital Sign ] ) . Within a private , integrated health care system , 54 adult primary care clinics were stratified by medical center and r and omly assigned in blocked groups of three to SBIRT by physicians ( PCP arm ) versus non-physician providers and medical assistants ( NPP and MA arm ) , versus usual care ( Control arm ) . NIH-recommended screening questions were added to the electronic health record ( EHR ) to facilitate SBIRT . We examined  screening  and brief intervention and referral rates by arm . We also examined patient- , physician- , and system-level factors affecting screening rates and , among those who screened positive , rates of brief intervention and referral to treatment . Results Screening rates were highest in the NPP and MA arm ( 51 % ) ; followed by the PCP arm ( 9 % ) and the Control arm ( 3.5 % ) . Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm . The PCP arm had higher brief intervention and referral rates ( 44 % ) among patients screening positive than either the NPP and MA arm ( 3.4 % ) or the Control arm ( 2.7 % ) . Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm . Conclusion Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation . Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models . Trial registration : Clinical Trials Importance An abdominal aortic aneurysm ( AAA ) is typically defined as aortic enlargement with a diameter of 3.0 cm or larger . The prevalence of AAA has declined over the past 2 decades among screened men 65 years or older in various European countries . The current prevalence of AAA in the United States is unclear because of the low uptake of screening . Most AAAs are asymptomatic until they rupture . Although the risk for rupture varies greatly by aneurysm size , the associated risk for death with rupture is as high as 81 % . Objective To up date its 2014 recommendation , the USPSTF commissioned a review of the evidence on the effectiveness of 1-time and repeated screening for AAA , the associated harms of screening , and the benefits and harms of available treatments for small AAAs ( 3.0 - 5.4 cm in diameter ) identified through screening . Population This recommendation applies to asymptomatic adults 50 years or older . However , the r and omized trial evidence focuses almost entirely on men aged 65 to 75 years . Evidence Assessment Based on a review of the evidence , the USPSTF concludes with moderate certainty that screening for AAA in men aged 65 to 75 years who have ever smoked is of moderate net benefit . The USPSTF concludes with moderate certainty that screening for AAA in men aged 65 to 75 years who have never smoked is of small net benefit . The USPSTF concludes that the evidence is insufficient to determine the net benefit of screening for AAA in women aged 65 to 75 years who have ever smoked or have a family history of AAA . The USPSTF concludes with moderate certainty that the harms of screening for AAA in women aged 65 to 75 years who have never smoked and have no family history of AAA outweigh the benefits . Recommendations The USPSTF recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked . ( B recommendation ) The USPSTF recommends that clinicians selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked rather than routinely screening all men in this group . ( C recommendation ) The USPSTF recommends against routine screening for  AAA  with ultrasonography in women who have never smoked and have no family history of AAA . ( D recommendation ) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA with ultrasonography in women aged 65 to 75 years who have ever smoked or have a family history of AAA . ( I statement ) Last winter , the U.S. Preventive Services Task Force ( USPSTF ) gave a positive recommendation ( B grade ) for  lung cancer screening with low-dose computed tomography . The recommendation applies to high-risk adults aged 55 to 80 years with a smoking history of at least 30 pack-years who are still smoking or have quit within the past 15 years ( 1 ) . The USPSTF based its recommendation on the l and mark National Lung Screening Trial ( NLST ) ( 2 ) , which provided evidence about the efficacy of screening but did not answer questions about effectiveness when implemented in everyday clinical practice . The recommendation , as noted in an accompanying editorial , leaves many of these critical issues unaddressed ( 3 ) . Indeed , the Medicare Evidence Development & Coverage Advisory Committee recently concluded that there was inadequate evidence to recommend national coverage for lung cancer screening ( 4 ) . This conclusion highlights the controversy over what constitutes sufficient evidence to support widespread implementation of a new technology . It has also heightened the tension between advocates who are eager to see wide deployment of screening quickly and others who are concerned about the ability of health care systems to provide a low-dose computed tomography screening program to the potentially large number of patients meeting criteria while still minimizing harms ( 4 ) . That a new intervention can work in r and omized trials does not guarantee that it will work as well when delivered in real-world practice , nor that the benefits in the community will justify the possible harms and costs ( including opportunity costs ) . Should these unanswered questions delay implementation of screening pending further study , or do the potential benefits compel their early adoption ? A middle-ground approach between early adoption and waiting years for more conclusive evidence is to carefully plan and evaluate a comprehensive approach to lung cancer screening , including a staged and limited implementation and evaluation program before broader implementation . The Veterans Health Administration ( VHA ) , the nation 's largest integrated health care system , has chosen this approach by developing a 2-year clinical demonstration project involving 8 VHA medical centers that serve more than 500000 veterans . This decision is based on some of the uncertainties , as outlined by the Medicare Evidence Development & Coverage Advisory Committee , as well as questions about the effect of screening on our patients , our staff , and our system . At the same time , the compelling results of NLST and high burden of smoking and lung cancer among veterans argue against a wait- and -see approach . Before committing to widespread screening , we want to determine the following : Can we effectively identify the right c and i date s to offer screening in the course of routine care ? What will the uptake of screening be and what re sources ( both technology and people ) are needed to meet that dem and ? Can we provide screening and follow-up ( including for the many patients with benign nodules ) with accuracy , efficiency , and safety similar to that achieved in the NLST ? Are the overall outcomes in our patients with early-stage cancer ( especially those who are older with more comorbid conditions ) compatible with a benefit of early detection ? To ensure that all veterans benefit , and not just those who request them , the VHA takes a proactive approach to all preventive programs . It is critically important to learn how to do this efficiently and effectively . At demonstration sites , annual screening will be provided , as recommended by the USPSTF . Full-time coordinators hired for the project will provide clinical coordination for patients who choose to be screened , using newly developed tracking tools and data bases . Structure , process , and outcome measures have been developed using quantitative and qualitative data from clinical data in electronic medical records , regular reports from pilot sites , quality assessment s of radiology reports , surveys and interviews of key clinical staff , and cost estimates for the screening program ( 5 ) . Clinical data include demographic characteristics , smoking history , and health status of those screened ; descriptions of identified nodules ; numbers and types of scans and other procedures performed initially and to evaluate abnormal findings ; adverse events from invasive procedures ; numbers and types of incidental findings and their follow-up ; and lung cancer cases diagnosed . These data will help assess whether the predominantly older , male VHA population with several chronic conditions has different outcomes with screening from those of the younger , healthier NLST population . At its conclusion , the project team will make recommendations about the processes and re sources needed for wider VHA dissemination of a lung cancer screening program and , if deemed feasible , appropriate metrics to monitor the process going forward . This quality improvement project , which is design ed to assess implementation , will not be able to determine the effect of screening on mortality rates . However , it will help determine whether the VHA can provide high- quality screening while minimizing possible harms , whether outcomes vary by site or patient group , and what re sources would be needed for national implementation . The VHA faces challenges in taking the time to implement screening in a limited way . Public interest in lung cancer screening has helped prompt individual screening programs at many VHA medical centers outside the demonstration project , potentially creating inconsistencies across the organization . Even if the demonstration project is successful , VHA-wide implementation of lung cancer screening will be challenging for a system of 151 medical centers of varying size and capacity , and it will require new processes to monitor quality , ensure adequate capacity , and track outcomes . The complexity of such a program can not be underestimated . In addition , we will need to be careful that a focus on implementation of a screening program does not detract attention from a far more effective means of reducing lung cancer deaths : smoking cessation interventions . The VHA 's experience with implementation of a lung cancer screening program may provide valuable lessons learned for other large health care organizations . This extends beyond the screening registries required by many proponents of screening ( 6 , 7 ) to the development of tools for patient identification , data collection , quality assessment , and patient education . The VHA 's population and its payment structure may limit the generalizability of our experience , but we believe that documenting the VHA 's demonstration project 's challenges , successes , and failures may help the U.S. health care system decrease the morbidity and mortality rates due to lung cancer in a way that provides the best balance between benefits and harms Despite recent declines in both incidence and mortality ( 1 ) , colorectal cancer remains the second most common cause of death from cancer in the United States ( 2 ) . Screening for colorectal cancer reduces mortality by allowing physicians to detect cancer at earlier , more treatable stages , as well as to identify and remove adenomatous polyps ( asymptomatic benign precursor lesions that may lead to colorectal cancer ) . Many tests are available for screening , such as fecal occult blood tests ( FOBTs ) , flexible sigmoidoscopy , and colonoscopy . Screening with FOBT ( Hemoccult II , Beckman Coulter , Fullerton , California ) has been shown to reduce colorectal cancer mortality by 15 % to 33 % in r and omized , controlled trials ( 35 ) , and screening with more sensitive FOBTs , flexible sigmoidoscopy , colonoscopy , or combinations of these tests may reduce the burden of colorectal cancer even more ( 6 , 7 ) . In the absence of adequate clinical trial data on several recommended screening strategies , microsimulation modeling can provide guidance on the risks , benefits , and testing re sources required for different screening strategies to reduce the burden of colorectal cancer . In July 2002 , the U.S. Preventive Services Task Force ( USPSTF ) concluded that there was sufficient evidence to recommend strongly that all average-risk adults 50 years of age or older should be offered colorectal cancer screening ( 8) . However , the logistics of screening , such as the type of screening test , screening interval , and age at which to stop screening , were not evaluated in terms of the balance of benefits and potential harms . The USPSTF has again addressed recommendations for colorectal cancer screening with a systematic review of the evidence ( 9 ) on screening tests . For this assessment , the USPSTF requested a decision analysis to project expected outcomes of various strategies for colorectal cancer screening . Two independent microsimulation modeling groups from the Cancer Intervention and Surveillance Modeling Network ( CISNET ) , funded by the National Cancer Institute , used a comparative modeling approach to compare life-years gained relative to re source use of different strategies for colorectal cancer screening . Methods We used 2 microsimulation models  , MISCAN ( MIcrosimulation Screening Analysis ) ( 1012 ) and SimCRC ( Simulation Model of Colorectal Cancer ) ( 13 ) , to estimate the life-years gained relative to no screening and the colonoscopies required ( that is , an indicator for re source use and risk for complications ) for different colorectal cancer screening strategies defined by test , age at which to begin screening , age at which to stop screening , and screening interval . We aim ed to identify a set of recommendable strategies with similar clinical benefit and an efficient use of colonoscopy re sources . Using 2 models ( that is , a comparative modeling approach ) adds credibility to the results and serves as a sensitivity analysis on the underlying structural assumptions of the models , particularly pertaining to the unobservable natural history of colorectal cancer . Microsimulation Models The Appendix describes the MISCAN and SimCRC models , and st and ardized model profiles are available at cisnet.cancer.gov/profiles/. In brief , both models simulate the life histories of a large population of individuals from birth to death . As each individual ages , there is a chance that an adenoma will develop . One or more adenomas can occur in an individual , and each adenoma can independently develop into pre clinical ( that is , undiagnosed ) colorectal cancer ( Figure 1 ) . The risk for developing an adenoma depends on age , sex , and baseline individual risk . The models track the location and size of each adenoma ; these characteristics influence disease progression and the chance that the adenoma will be found by screening . The size of adenomas can progress from small ( 5 mm ) to medium ( 6 to 9 mm ) to large ( 10 mm ) . Some adenomas eventually become malignant , transforming to stage I pre clinical cancer . Pre clinical cancer has a chance of progressing through stages I to IV and may be diagnosed by symptoms at any stage . Survivorship after diagnosis depends on the stage of disease . Figure 1 . Natural history of disease as modeled by the Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer models . The opportunity to intervene in the natural history through screening is noted . The natural history component of each model was calibrated to 19751979 clinical incidence data ( 14 ) and adenoma prevalence from autopsy studies in the same period ( 1524 ) . We used this period because incidence rates and adenoma prevalence had not yet been affected by screening . We corrected the adenoma prevalence for studies of non-U.S. population s by using st and ardized colorectal cancer incidence ratios . The models use all-cause mortality estimates from the U.S. life tables and stage-specific data on colorectal cancer survival from the 19961999 Surveillance , Epidemiology , and End Results program ( 14 ) . Table 1 compares outcomes from the natural history components of the models . Table 1 . Comparison of the Natural History Outcomes from the Microsimulation Screening Analysis ( MISCAN ) and Simulation Model of Colorectal Cancer ( SimCRC ) Models The effectiveness of a screening strategy is modeled through a test 's ability to detect lesions ( that is , adenomas or pre clinical cancer ) . Once screening is introduced , a simulated person who has an underlying lesion has a chance of having it detected during a screening round depending on the sensitivity of the test for that lesion and whether the lesion is within the reach of the test . Screened persons without an underlying lesion can have a false-positive test result and undergo unnecessary follow-up colonoscopy . Hyperplastic polyps are not modeled explicitly , but their detection is reflected in the specificity of the screening tests . The models incorporate the risk for fatal complications associated with perforation during colonoscopy . Both models have been vali date d against the long-term reductions in incidence and mortality of colorectal cancer with annual FOBT reported in the Minnesota Colon Cancer Control Study ( 3 , 25 , 26 ) and show good concordance with the trial results . Strategies for Colorectal Cancer Screening In consultation with the USPSTF , we included the following basic strategies : 1 ) no screening , 2 ) colonoscopy , 3 ) FOBT ( Hemoccult II , Hemoccult SENSA [ Beckman Coulter ] , or fecal immunochemical testing ) , 4 ) flexible sigmoidoscopy ( with biopsy ) , and 5 ) flexible sigmoidoscopy combined with Hemoccult SENSA . For each basic strategy , we evaluated start ages of 40 , 50 , and 60 years and stop ages of 75 and 85 years . For the FOBT strategies , we considered screening intervals of 1 , 2 , and 3 years , and for the sigmoidoscopy and colonoscopy strategies , we considered intervals of 5 , 10 , and 20 years . These variations result ed in 145 strategies : 90 single-test strategies , 54 combination-test strategies , and 1 no-screening strategy . The stop age reflects the oldest possible age at which to screen , but the actual stopping age is dictated by the start age and screening interval . In the base case , we assumed 100 % adherence for screening tests , follow-up of positive findings , and surveillance of persons found to have adenomas . Individuals with a positive FOBT result or with an adenoma detected by sigmoidoscopy were referred for follow-up colonoscopy . For years in which both tests were due for the combined strategy , the FOBT was performed first ; if the result was positive , the patient was referred for follow-up colonoscopy . In those years , flexible sigmoidoscopy was done only for patients with a negative FOBT result . If findings on follow-up colonoscopy were negative , the individual was assumed to undergo subsequent screening with colonoscopy with a 10-year interval ( as long as results of the repeated colonoscopy were negative ) and did not return to the initial screening schedule , as is the recommendation of the U.S. Multi-Society Task Force and American Cancer Society ( 7 , 27 ) . All individuals with an adenoma detected were followed with colonoscopy surveillance per the Multi-Society guidelines ( 27 , 28 ) . The surveillance interval depended on the number and size of the adenomas detected on the last colonoscopy ; it ranged from 3 to 5 years and was assumed to continue for the remainder of the person 's lifetime . We estimated the test characteristics of colorectal cancer screening from a review of the available literature ( Table 2 ) ( 29 ) . We conducted this review independently of and parallel in time with the systematic evidence review performed for the USPSTF ( 9 ) . Table 2 . Test Characteristics Used in the Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer Models Evaluation of Outcomes Determination of Efficient Strategies The most effective strategy was defined as the one with the greatest life-years gained relative to no screening . However , it is important to consider the relative intensity of test use required to achieve those gains . The more effective strategies tended to be associated with more colonoscopies on average in a person 's lifetime , which translated into an increased risk for colonoscopy-related complications . We used an approach that mirrors that of cost-effectiveness analysis ( 30 ) to identify the set of efficient , or dominant , strategies within each test category . A strategy was considered dominant when no other strategy or combination of strategies provided more life-years with the same number of colonoscopies . We conducted this analysis separately for each of the 5 basic screening strategies because the number of noncolonoscopy tests differed by strategy . We then ranked the efficient screening strategies by increasing effectiveness and calculated the incremental number of colonoscopies ( COL ) per 1000 , the incremental life-years gained ( LYG ) per 1000 , and the incremental number of colonoscopies necessary to achieve 1 year of life ( Among over 5million people in the USA with dementia , neuropsychiatric symptoms ( NPS ) are almost universal , occurring across disease etiology and stage . If untreated , NPS can lead to significant morbidity and mortality including increased cost , distress , depression , and faster disease progression , as well as heightened burden on families . With few pharmacological solutions , identifying nonpharmacologic strategies is critical . We describe a r and omized clinical trial , the Dementia Behavior Study , to test the efficacy of an activity program to reduce significant existing NPS and associated caregiver burden at 3 and 6months compared to a control group intervention . Occupational therapists deliver 8 in-home sessions over 3months to assess capabilities and interests of persons with dementia , home environments , and caregiver knowledge , and readiness from which activities are developed and families trained in their use . Families learn to modify activities for future declines and use strategies to address care challenges . The comparison group controls for time and attention and involves 8 in-home sessions delivered by health educators who provide dementia education , home safety recommendations , and advanced care planning . We are r and omizing 250 racially diverse families ( person with dementia and primary caregiver dyads ) recruited from community-based social services , conferences and media announcements . The primary outcome is change in agitation/aggression at 3 and 6months . Secondary outcomes assess quality of life of persons with dementia , other behaviors , burden and confidence of caregivers , and cost and cost effectiveness . If benefits are supported , this activity intervention will provide a clinical ly meaningful approach to prevent , reduce , and manage NPS The U.S. Preventive Services Task Force recommends that clinicians screen adults for tobacco and alcohol abuse and provide appropriate interventions . This study employed direct observation and interactional analysis of medical visits to investigate factors associated with physician discussion of tobacco and alcohol use with patients . New adult patients were r and omly assigned to primary care at a university medical center .  Videotapes of the visits were analyzed using the Davis observation code . Regression equations related discussion s of substance use ( alcohol and other substances ) , smoking , and health promotion to patient health status , depression , age , education , income , gender , alcohol abuse , and current smoking . Patients reporting better physical health were more likely to have their physicians employ a practice style emphasizing addiction behaviors ( p = .0186 ) . Substance use ( p = .0117 ) and health promotion counseling ( p = .0130 ) occurred more frequently with younger patients . Physicians discussed substance use ( p = < .0001 ) and addiction ( p < .0001 ) more often with male patients . Problem drinkers were more likely to have physicians address their substance use ( p = .0069 ) and focus on addiction behaviors ( p = .0017 ) . Physicians adopted an addiction-oriented practice style ( p < .0001 ) , addressing substance use ( p = .0009 ) and smoking ( p < .0001 ) , more often with patients who smoked . Physicians appear more apt to discuss these behavioral risk factors with healthier , younger , male patients who abuse tobacco and alcohol ABSTRACT . The US Preventive Services Task Force ( USPSTF ) has recommended depression screening for adults . Screening mothers has special importance to pediatricians because of the impact of maternal depression on children . The two screening questions endorsed by the USPSTF may allow pediatricians to screen mothers during routine well child care . This study explores the feasibility and yield of interview- and paper-based pediatric screening for maternal depression during well child visits . A structured interview script was developed to inquire about maternal depression . It included the two- question screen and required less than 1 minute to administer . An alternative paper-based screen asked the two questions after a brief written introduction providing the rationale . Four community pediatric practice s in New Hampshire and Maine were trained in both screening approaches and developed plans on how to respond to positive screens ( either question positive ) . The 11 providers at these sites tested the two approaches on two different series of mothers at well child visits . The pediatricians also reported barriers to the screening inquiries , maternal responses , and subsequent clinician actions and referrals . The pediatricians screened 250 mothers via the scripted interview .  In a second trial , 223 women had paper-based depression screening .  Yields from the paper-based screen were 22.9 % versus 5.7 % for the interview-based screener . Pediatricians also took on the new role of discussion of possible depression in about two thirds of cases . Subsequently , 7.6 % of all women with paper-based screening were referred to mental health versus 1.6 % with the interview-based screening . With the interview , mothers of children younger than 1 year of age were less likely to screen positive than those with older children ( 1.9 % vs. 8.5 % , p = .04 ) . With the paper-based screener , no age differences in positive screen rates occurred . While both approaches to screening were feasible in primary care , the yield from the two different approaches differed substantially . This finding deserves exploration in future studies . With either of these screening approaches , pediatricians could enhance their detection of mothers at risk of depression . The outcomes of pediatrician screening and the best approach to follow-up care still need to be determined Study Design . Clinical practice guideline . Objective . To develop evidence -based recommendations on use of interventional diagnostic tests and therapies , surgeries , and interdisciplinary rehabilitation for low back pain of any duration , with or without leg pain . Summary of Background Data . Management of patients with persistent and disabling low back pain remains a clinical challenge . A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing , but in some cases their utility remains uncertain or controversial . Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain . Methods . A multidisciplinary panel was convened by the American Pain Society . Its recommendations were based on a systematic review that focused on evidence from r and omized controlled trials . Recommendations were grade d using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations , Assessment , Development , and Evaluation Working Group . Results . Investigators review ed 3348 abstract s. A total of 161 r and omized trials were deemed relevant to the recommendations in this guideline . The panel developed a total of 8 recommendations . Conclusion . Recommendations on use of interventional diagnostic tests and therapies , surgery , and interdisciplinary rehabilitation are presented . Due to important trade-offs between potential benefits , harms , costs , and burdens of alternative therapies , shared decision-making is an important component of a number of the recommendations BACKGROUND Current diabetes management guidelines offer blueprints for providers , yet type 2 diabetes control is often poor in disadvantaged population s. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems .  Group visits offer promise for delivering care to diabetic patients , as visits are lengthier and can be more frequent , more organized , and more educational . OBJECTIVE To evaluate the effect of group visits on clinical outcomes , concordance with 10 American Diabetes Association ( ADA ) guidelines [ American Diabetes Association , Diabetes Care , 28:S4–36 , 2004 ] and 3 United States Preventive Services Task Force ( USPSTF ) cancer screens [ U.S. Preventive Services Task Force , http://www.ahrq.gov/clinic/uspstf/re source .htm , 2003 ] . RESEARCH DESIGN AND METHODS A 12-month r and omized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient – physician dyad . Clinical outcomes ( HbA1c , blood pressure [ BP ] , lipid profiles ) were assessed at 6 and 12 months and quality of care measures ( adherence to 10 ADA guidelines and 3 USPSTF cancer screens ) at 12 months . RESULTS At both measurement points , HbA1c , BP , and lipid levels did not differ significantly for patients attending group visits versus those in usual care . At 12 months , however , patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators ( p < .0001 ) and higher screening rates for cancers of the breast ( 80 vs. 68 % , p = .006 ) and cervix ( 80 vs 68 % , p = .019 ) . CONCLUSIONS Group visits can improve the quality of care for diabetic patients , but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes OBJECTIVE To assess to what extent family physicians perform the maneuvers for elderly patients recommended by the Canadian Task Force on Preventive Health Care ( CTF ) , and to compare physicians ' performance among patients who had structured periodic health examinations with performance among those who did not . DESIGN Retrospective chart audit . SETTING Family practice unit in a secondary care , university-affiliated hospital in Toronto , Ont . PARTICIPANTS Records of 136 community-dwelling patients aged 70 and older . Of 340 r and omly selected charts , 108 were excluded and 51 were inaccessible ; 100 had had PHEs , and a r and om sample of 36 who had attended the clinic three or more times was chosen from the remaining 81 [ corrected ] . MAIN OUTCOME MEASURES Proportion of patients who received the recommended screening maneuvers . RESULTS Charts were audited for 100 patients who had structured periodic health examinations and 36 who did not but who attended the clinic three or more times during an 18-month period . Screening rates among patients who had structured examinations ranged from 28 % of patients screened for hearing impairment to 100 % screened for hypertension . Patients who did not have structured examinations were significantly less likely to receive screening maneuvers . CONCLUSIONS Screening rates were below desirable levels in patients older than 70 years .  Screening during structured health examinations seems to be more effective than opportunistic screening for patients 70 and older OBJECTIVES People with co-occurring severe mental illness and a substance use disorder are at markedly elevated risk of infection from HIV , hepatitis B virus ( HBV ) , and hepatitis C virus ( HCV ) , but they generally do not receive basic recommended screening or preventive and treatment services . Barriers to services include lack of programs offered by mental health providers and client refusal of available services . Clients from racial-ethnic minority groups are even less likely to accept recommended services . The intervention tested was design ed to facilitate integrated infectious disease programming in mental health setting s and to increase acceptance of such services among clients . METHODS A r and omized controlled trial ( N=236 ) compared enhanced treatment as usual ( control ) with a brief intervention to deliver best- practice services for blood-borne diseases in an urban sample of clients with co-occurring disorders who were largely from racial-ethnic minority groups . The " STIRR " intervention included Screening for HIV and HCV risk factors , Testing for HIV and hepatitis , Immunization against hepatitis A and B , Risk reduction counseling , and medical treatment Referral and support at the site of mental health care . RESULTS Clients r and omly assigned to the STIRR intervention had high levels ( over 80 % ) of participation and acceptance of core services . They were more likely to be tested for HBV and HCV , to be immunized against hepatitis A virus and HBV , and to increase their knowledge about hepatitis and reduce their substance abuse . However , they showed no reduction in risk behavior , were no more likely to be referred to care , and showed no increase in HIV knowledge . Intervention costs were $ 541 per client ( including $ 234 for blood tests ) . CONCLUSIONS STIRR appears to be efficacious in providing a basic , best- practice package of interventions for clients with co-occurring disorders Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends against routine screening with resting electrocardiography ( ECG ) , exercise treadmill test ( ETT ) , or electron-beam computerized tomography ( EBCT ) scanning for coronary calcium for either the presence of severe coronary artery stenosis ( CAS ) or the prediction of coronary heart disease ( CHD ) events in adults at low risk for CHD events . This is a grade D recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found at least fair evidence that ECG or ETT can detect some asymptomatic adults at increased risk for CHD events independent of conventional CHD risk factors ( see Clinical Considerations ) and that ETT can detect severe CAS in a small number of asymptomatic adults . Similar evidence for EBCT is limited . In the absence of evidence that such detection by ECG , ETT , or EBCT among adults at low risk for CHD events ultimately results in improved health outcomes , and because false-positive tests are likely to cause harm , including unnecessary invasive procedures , overtreatment , and labeling , the USPSTF concluded that the potential harms of routine screening for CHD in this population exceed the potential benefits . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Appendix Table 1 . U.S. Preventive Services Task Force Grade s and Recommendations Appendix Table 2 . U.S. Preventive Services Task Force Strength of Overall Evidence The USPSTF found insufficient evidence to recommend for or against routine screening with ECG , ETT , or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events . This is a grade I recommendation . The USPSTF found inadequate evidence to determine the extent to which the added detection offered by ECG , ETT , or EBCT ( beyond that obtained by ascertainment of conventional CHD risk factors ) ( see Clinical Considerations ) would result in interventions that lead to improved CHD-related health outcomes among adults at increased risk for CHD events . Although there is limited evidence to determine the magnitude of harms from screening this population , harms from false-positive tests ( that is , unnecessary invasive procedures , overtreatment , and labeling ) are likely to occur . As a result , the USPSTF could not determine the balance between benefits and harms of screening this population for CHD . Clinical Considerations Several factors are associated with a higher risk for CHD events ( the major ones are nonfatal myocardial infa rct ion and coronary death ) , including older age , male gender , high blood pressure , smoking , abnormal lipid levels , diabetes , obesity , and sedentary lifestyle . A person 's risk for CHD events can be estimated on the basis of the presence of these factors . Calculators are available to ascertain a person 's risk for a CHD event ; for example , a calculator to estimate a person 's risk for a CHD event in the next 10 years can be accessed at hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof . Although the exact risk factors that constitute each of these categories ( low or increased risk ) have not been established , younger adults ( that is , men<50 years of age and women<60 years of age ) who have no other risk factors for CHD ( < 5 % to 10 % 10-year risk ) are considered to be at low risk . Older adults , or younger adults with one or more risk factors ( > 15 % to 20 % 10-year risk ) , are considered to be at increased risk . Screening with ECG , ETT , and EBCT could potentially reduce CHD events in 2 ways : either by detecting people at high risk for CHD events who could benefit from more aggressive risk factor modification or by detecting people with existing severe CAS whose life could be prolonged by coronary artery bypass grafting ( CABG ) surgery . However , the evidence is inadequate to determine the extent to which people detected through screening in either situation would benefit from either type of intervention . The consequences of false-positive tests may potentially outweigh the benefits of screening . False-positive tests are common among asymptomatic adults , especially women , and may lead to unnecessary diagnostic testing , overtreatment , and labeling . Because the sensitivity of these tests is limited , screening could also result in false-negative results . A negative test does not rule out the presence of severe CAS or a future CHD event . For people in certain occupations , such as pilots and heavy equipment operators ( for whom sudden incapacitation or sudden death may endanger the safety of others ) , considerations other than the health benefit to the individual patient may influence the decision to screen for CHD . Although some exercise programs initially screen asymptomatic participants with ETT , there is not enough evidence to determine the balance of benefits and harms of this practice . Discussion Coronary heart disease is the leading cause of death in the United States ; more than 700000 of the deaths in 2000 were due to heart disease ( 1 ) . The overall costs of CHD and stroke in 2003 are estimated to be greater than $ 350 billion ( 2 ) . Many clinicians ascertain a person 's overall risk for CHD events by screening for cardiac risk factors and incorporating that information into risk prediction equations derived from the Framingham or other cohort studies ( 3 , 4 ) . Asymptomatic adults clearly benefit from risk factor modification proportional to their degree of CHD risk ( that is , more intensive risk factor modification for people at higher risk ) ( 5 ) . Since those at high risk for CHD may already be receiving interventions to maximally reduce their risk for CHD events , screening may potentially be of greatest benefit to those presumed to be at intermediate risk for CHD who could be reclassified as being at high risk ( and thus treated more aggressively ) after additional testing . In addition to risk factor reduction , persons with symptoms of CHD who have severe CAS ( defined as either triple-vessel or left main coronary artery atherosclerotic disease with poor left ventricular function ) clearly benefit from CABG or percutaneous transluminal coronary angioplasty ( 6 - 8 ) . Among the asymptomatic population , those at higher risk for CHD events have a higher prevalence of severe CAS ; thus , the yield of screening is expected to be greater in this population . However , it is uncertain whether this increased yield increases the detection of people with severe CAS to an important degree and whether invasive revascularization procedures would benefit those who are asymptomatic as much as those who have symptoms of CAS . The USPSTF review ed the evidence as to whether supplementing the conventional CHD risk ascertainment strategy with additional screening using ECG , ETT , or EBCT , or using these 3 tests to identify people with severe CAS earlier , would lead to improved health outcomes in asymptomatic persons . The USPSTF found no r and omized , controlled trials with health outcomes that examined the extent to which  ECG , ETT , or EBCT scanning for coronary calcium provided additional prognostic information beyond the currently used risk factor calculations . The Task Force further found that the 3 screening testsECG , ETT , and EBCThave poor to fair accuracy in predicting CHD events . Systematic review s have reported that the sensitivity of resting ECG abnormalities for CHD events is low ( 3 , 9 ) . The prevalence of the most common ECG abnormalities ( Q waves , left ventricular hypertrophy , bundle-branch blocks , and ST-segment depression ) ranges from 1 % to 10 % ( 3 ) . Only a few studies have examined ECG abnormalities in the black population . Although major ECG abnormalities may be more prevalent in black men than in white men , these abnormalities may not confer the same risk for CHD death in black men ( relative risk , 1.95 [ 95 % CI , 0.93 to 4.11 ] ) as in white men ( relative risk , 2.72 [ CI , 1.47 to 5.04 ] ) ( 10 ) . The sensitivity of ETT  for the prediction of CHD events 3 to 12 years in the future ranges from 40 % to 62 % ; the positive predictive value ( PPV ) ranges from 6 % to 48 % . The higher sensitivity of ETT  reported in older studies may not be accurate because of the possibility of spectrum bias ( 11 , 12 ) . The prevalence of an abnormal ETT ( ST-segment depression 1 mm ) reportedly ranges from 5 % to 25 % ( 3 ) . The yield of ETT  in detecting severe CAS in asymptomatic middle-aged men is estimated to be 0.5 % ( 3 , 13 ) . The PPV for future CHD in recent cohort studies ( most of them conducted with asymptomatic men ) is low ( range , 6 % to 48 % ) ( 3 ) . Adding nuclear perfusion to ECG analysis may increase sensitivity somewhat ; however , the low PPV of ETT is due mainly to the low prevalence of CHD in asymptomatic persons and can not be corrected simply by improving test accuracy . For patients with symptoms of CHD , EBCT has a sensitivity of 80 % and a specificity of 40 % for detecting angiographically demonstrated CAS ( 14 ) ; similar data for those who have no symptoms are lacking . A systematic review reported that higher calcium scores on EBCT were associated with higher risk for CHD events ( 3 ) . This review concluded that EBCT may have a role in better defining risk for CHD events in those who have been identified as being at intermediate risk based on traditional risk factors , but no study has examined the effect of EBCT data on clinical decision making ( 3 ) . Potential harms of screening asymptomatic patients for CHD include unnecessary invasive testing ( for example , coronary angiography ) and labeling of those who have had false-positive test results . In low-risk asymptomatic population s , most positive ECG test results occur in those who will not have a CHD event in the next 5 to 10 years ( 3 ) . One study reported that 71 % of those without symptoms who had an abnormal ETT had no angiographically demonstrable CAS ( 15 ) . While the yield of screening is low in those at low risk for CHD , the potential for Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A , C , or E ; multivitamins with folic acid ; or antioxidant combinations for the prevention of cancer or cardiovascular disease . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found poor evidence to determine whether supplementation with these vitamins reduces the risk for cardiovascular disease or cancer . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) The available evidence from r and omized trials is either inadequate or conflicting , and the influence of confounding variables on observed outcomes in observational studies can not be determined . As a result , the USPSTF could not determine the balance of benefits and harms of routine use of supplements of vitamins A , C , or E ; multivitamins with folic acid ; or antioxidant combinations for the prevention of cancer or cardiovascular disease . The USPSTF recommends against the use of beta-carotene supplements , either alone or in combination , for the prevention of cancer or cardiovascular disease . This is a grade D recommendation . The USPSTF found good evidence that -carotene supplementation provides no benefit in the prevention of cancer or cardiovascular disease in middle-aged and older adults . In two trials restricted to heavy smokers , -carotene supplementation was associated with higher incidence of lung cancer and higher all-cause mortality . The USPSTF concludes that -carotene supplements are unlikely to provide important benefits and might cause harm in some groups . Clinical Considerations The USPSTF did not review evidence regarding vitamin supplementation for patients with known or potential nutritional deficiencies , including pregnant and lactating women , children , elderly persons , and people with chronic illnesses .  Dietary supplements may be appropriate for people whose diet does not provide the recommended dietary intake of specific vitamins . Individuals may wish to consult a health care provider to discuss whether dietary supplements are appropriate . With the exception of vitamins for which there is compelling evidence of net harm ( for example , beta-carotene supplementation in smokers ) , there is little reason to discourage people from taking vitamin supplements . Patients should be reminded that taking vitamins does not replace the need to eat a healthy diet . All patients should receive information about the benefits of a diet high in fruits and vegetables , as well as information on other foods and nutrients that should be emphasized or avoided in their diet ( see the 2002 USPSTF recommendations on counseling to promote a healthy diet [ 1 ] ) . Patients who choose to take vitamins  should be encouraged to adhere to the dosages recommended in the Dietary Reference Intakes of the Institute of Medicine . Some vitamins , such as A and D , may be harmful in higher doses ; therefore , doses greatly exceeding the Recommended Dietary Allowance or Adequate Intake should be taken with care while considering whether potential harms outweigh potential benefits . Vitamins and minerals sold in the United States are classified as dietary supplements , and there is a degree of quality control over content if they have a U.S. Pharmacopeia seal ( 2 ) . Nevertheless , imprecision in the content and concentration of ingredients could pose a theoretical risk not reflected in clinical trials using calibrated compounds . The adverse effects of beta-carotene on smokers have been observed primarily in those taking large supplemental doses . There is no evidence to suggest that beta-carotene is harmful to smokers at levels occurring naturally in foods . The USPSTF did not review evidence supporting folic acid supplementation among pregnant women to reduce neural tube defects . In 1996 , the USPSTF recommended folic acid for all women who are planning , or capable of , pregnancy ( see the 1996 USPSTF chapter on screening for neural tube defects [ 3 ] ) . Clinicians and patients should discuss the possible need for vitamin supplementation when taking certain medications ( for example , folic acid supplementation for patients taking methotrexate ) . Scientific Evidence The USPSTF review s ( 4 - 6 ) focused on the quality of the evidence regarding the effect of routine supplementation with certain vitamins on primary prevention of cancer and cardiovascular disease . These review s were undertaken because of the growing epidemiologic evidence that dietary factors may play a role in the etiology of these diseases ( 7 - 9 ) . The review s focused on prospect i ve trials of vitamin supplementation and observational studies of associations between the use of specific supplements and the risk for cancer or cardiovascular disease . The value of vitamins naturally occurring in food , the use of vitamin supplements for the prevention of other conditions ( for example , neural tube defects ) , and the use of vitamin supplements for the secondary prevention of complications in patients with existing disease were outside the scope of these review s. Vitamin A No prospect i ve trials have examined the effect of vitamin A supplements alone on the risk for cancer . Observational studies provide no evidence that such supplements prevent cancer in men . In women , observational studies have reported a statistically significant inverse association between use of vitamin A supplements and risk for colon and breast cancer ( 10 , 11 ) . Despite efforts to adjust for confounding variables , the observational , nonr and om design of these studies makes it difficult to assess the extent to which the reduced cancer risk is attributable to vitamin A or to other characteristics of women who take vitamin A supplements .  No evidence from prospect i ve trials is available regarding the benefits of vitamin A alone in preventing cardiovascular disease . One good- quality cohort study found no effect of vitamin A supplementation in reducing cardiovascular disease mortality ( 12 ) . Vitamin C No primary prevention trial of the effect of vitamin C supplementation alone on cancer or cardiovascular disease has been reported . Observational studies have generally shown no statistically significant associations between use of vitamin C supplements and risk for cancer of the breast , prostate , colon , or lung ( 12 - 14 ) . The observational cohort studies examining the effects of vitamin C on cardiovascular disease have produced inconsistent results ( 12 , 15 , 16 ) . Vitamin E Only a few trials have examined the effects of vitamin E on the primary prevention of cancer or cardiovascular disease . A r and omized , controlled trial ( RCT ) involving Finnish male smokers found that vitamin E supplementation is not protective against lung cancer but may have a beneficial impact on prostate cancer ( 14 ) . Because prostate cancer was not a primary end point of the trial and the trial had other limitations , further evidence is needed to confirm this finding . Observational studies have shown no statistically significant association between use of vitamin E supplements and risk for prostate , lung , or breast cancer ( 5 ) . One study suggested that vitamin E protects against colon cancer , but the influence of confounding variables can not be fully excluded ( 17 ) . Among primary prevention trials , two good- quality trials ( 14 , 18 ) and one fair- quality trial ( 19 ) found no statistically significant benefit of vitamin E supplementation in preventing cardiovascular disease ( 20 ) . Only one of seven trials of vitamin E supplementation for secondary prevention demonstrated a statistically significant reduction in cardiac events ( 4 ) . Some prospect i ve cohort studies have suggested a significant benefit , but the results are mixed and the influence of confounding variables can not be excluded ( 4 ) . -Carotene A consistent body of evidence from clinical trials suggests that beta-carotene supplementation does not decrease the risk for lung , prostate , colon , breast , or nonmelanoma skin cancer ( 14 , 21 - 25 ) . -Carotene supplements were associated with an increased risk for lung cancer among smokers , especially heavy smokers , in two RCTs ( 14 , 25 ) . Results from four RCTs demonstrated no reduced risk for cardiovascular events or death after beta-carotene supplementation ( 14 , 21 , 22 , 26 - 28 ) . Antioxidant Vitamin Combinations Studies of the effects of antioxidant vitamin combinations to prevent cancer have yielded mixed results . A recent RCT reported no statistically significant effect of daily supplementation with a combination of antioxidants : vitamin E , vitamin C , and beta-carotene ( 29 ) . Some studies have suggested an adverse effect of antioxidant combinations on cancer , but the results may have been confounded by the inclusion of beta-carotene ( 5 ) . Some observational studies of antioxidant vitamin combinations have suggested a benefit in preventing cardiovascular disease ( 13 , 30 , 31 ) , but other studies , including well- design ed RCTs , have shown no benefit ( 29 , 32 , 33 ) . One secondary prevention trial showed an increase in all-cause mortality among women taking antioxidant supplements  ( 34 ) . Multiple Vitamin Combinations The incremental benefit of taking supplemental doses of folic acid and B vitamins has been examined by comparing the outcomes of observational studies while controlling for the total intake of antioxidant vitamin supplements ( 35 ) . In these analyses , folic acid supplementation was associated with significantly decreased risk for colon cancer , but the protective effect requires confirmation in prospect i ve trials . There is conflicting evidence regarding the use of multivitamins and the risk for cardiovascular disease . Among cohort studies , one good- quality study reported a statistically significant reduction in coronary events ( 36 ) , two good- quality studies reported no statistically significant effect on mortality ( 16 , 37 ) , and one This issue of JAMA contains the latest US Preventive Services Task Force ( USPSTF ) recommendation statement on statins for prevention of cardiovascular disease in adults,1 along with the accompanying evidence report and systematic review 2 on which the recommendations are based . The evidence report summarized data from 19 trials including a total of 71 344 patients and concluded that statin therapy was associated with reduced risk of all-cause and cardiovascular mortality and cardiovascular disease ( CVD ) events . Thus , the task force recommended “ initiating use of lowto moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors and a calculated 10-year CVD event risk of 10 % or greater ( B recommendation ) ” or “ 7.5 % to 10 % ( C recommendation ) .”1 Although the task force did their usual careful job of review ing the evidence , the evidence for treating asymptomatic persons with statins does not appear to merit a grade B or even a grade C recommendation . The task force evidence report estimated an absolute benefit for use of statins of 0.40 % for all-cause mortality and 0.43 % for cardiovascular mortality and indicated that the absolute benefit was greater for patients at greater baseline risk.2 Notably , the evidence report did not exclude studies that included patients taking statins for secondary prevention , who have a higher baseline risk of cardiac events and death and thus are more likely to benefit from therapy that inflates the benefit attributed to a primary prevention population . The task force did perform a sensitivity analysis that excluded 3 trials with persons for whom there were prior “ hard ” cardiovascular events and obtained similar results of benefits ( eTable 5 in the article by Chou et al2 ) . This sensitivity analysis did not exclude WOSCOPS , which included patients receiving statins for secondary prevention—5 % had angina and 3 % had intermittent claudication,3 accounting for 15 % of the total weight in the meta- analysis . In contrast , a meta- analysis of 11 studies and 65 229 patients receiving statins for primary prevention , in which patients receiving statins for secondary prevention were excluded , found no benefit of statins for reducing all-cause mortality.4 The confidence intervals of these 2 analyses overlap , and the difference between these findings likely reflects differences in studies included . The USPSTF and authors of the evidence report did not have access to the primary data ( clinical study reports and anonymized patient-level data ) from the statin clinical trials . Rather , they had to rely on peer- review ed published reports as the basis for these recommendations . Exacerbating the potential bias , all of the trials included in the task force evidence report2 were industry-sponsored except 1 trial,5 and that trial contributed 0.2 % of the weight to the mortality calculation . Industry-sponsored studies have been shown to report greater benefit and lesser adverse effects than noncommercially sponsored trials of the same drugs.6 Whether this is true for statins and primary prevention of CVD is unknown . Among the 19 r and omized clinical trials of statins vs placebo or no statin included in the evidence report for the task force recommendations , only 15 reported all-cause mortality , 10 reported cardiovascular mortality , 12 reported fatal and nonfatal myocardial infa rct ion  , and 13 reported fatal and nonfatal stroke.2,7  Reliance on selective reporting of the most important outcomes , which are likely included in the clinical trial data , makes reporting bias possible . Furthermore , after allcause mortality , the comparative incidence of serious adverse events between treatment and control groups is arguably the second most important measure of the effect of active therapy in r and omized clinical trials . Underst and ing the evidence base in evaluating harms of statin therapy is also critically important . Although the benefits of any preventive therapy accrue according to risk of disease ( greater benefit in higher-risk patients ) , the harms of therapy usually distribute equally over all risk levels . Thus , persons at low risk have little chance of benefit but equal chance of harms and thus are more likely to have a net harm . The evidence base for harms of statins , despite the introduction of these drugs more than 20 years ago , is incomplete . Many of the trials did not ask about commonly reported statin effects , such as muscle pains and weakness , and only recorded myopathy , for which an increase in creatine kinase levels was required . Because most muscle problems do not involve an increase in creatine kinase levels , this leads to a significant underestimate of muscle problems . Other studies have estimated that closer to 20 % of statin users have muscle problems.8 Additionally , the actual trial data are largely held by the Cholesterol Treatment Trialists ’ Collaboration on behalf of the industry sponsor and have not been made available to other research ers , despite multiple requests over many years.9 Although reported rates of adverse events in clinical trials are low , this does not reflect the experience of clinicians who see patients who are taking statins . For instance , the experience of an NPR reporter with a calculated 2.9 % risk of heart disease over 10 years using the recommended American College of Cardiology/American Heart Association ( ACC/AHA ) risk calculator,10 but still prescribed a statin , and experiencing adverse effects from the medication , is typical of what many Related articles at jama.com BACKGROUND The U.S. Congress m and ated evaluations , initiated in 1989 , to determine whether extending Medicare benefits to include preventive services would improve health status , reduce costs of care , and improve health risk behaviors of beneficiaries . METHODS The Johns Hopkins Medicare Preventive Services Demonstration was a r and omized trial in which Medicare beneficiaries were assigned either to an intervention group that was offered yearly preventive visits for 2 years and optional counseling visits to their primary care provider or to a control group that received usual care . This report describes the effect of the intervention over a period of 2 years on smoking , problem alcohol use , and sedentary lifestyle . RESULTS Differences were observed between the intervention and control groups in the extent to which changes occurred in smoking and problem alcohol use , but none of the differences was statistically significant . The proportion of smokers who quit was higher in the intervention group than in the control group ( 24.2 vs 17.9 % , P = 0.09 ) . However , a higher proportion of problem drinkers in the control group improved ( 67.1 vs 57.0 % , P = 0.183 ) . There was virtually no difference between the intervention and the control groups in the proportion with improvement in sedentary lifestyle . CONCLUSIONS This study demonstrates the difficulty of bringing about health behavior change in older patients in the course of a yearly preventive visit for 2 years with their primary care physician when the visit encompasses screening and immunizations , as well as health behavior counseling directed by the physician . Further study is required to determine whether a more intense program of counseling for health behavior change among older persons by their primary care providers would be effective IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse , based in part on evidence of efficacy for unhealthy alcohol use . However , it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy . OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use ( any illicit drug use or prescription drug misuse)-a brief negotiated interview ( BNI ) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention . DESIGN , SETTING , AND PARTICIPANTS This 3-group r and omized trial took place at an urban hospital-based primary care internal medicine practice ; 528 adult primary care patients with drug use ( Alcohol , Smoking , and Substance Involvement Screening Test [ ASSIST ] substance-specific scores of ≥4 ) were identified by screening between June 2009 and January 2012 in Boston , Massachusetts . INTERVENTIONS Two interventions were tested : the BNI is a 10- to 15-minute structured interview conducted by health educators ; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master's-level counselors . All study participants received a written list of substance use disorder treatment and mutual help re sources . MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a vali date d calendar method at 6 months . Secondary outcomes included other self-reported measures of drug use , drug use according to hair testing , ASSIST scores ( severity ) , drug use consequences , unsafe sex , mutual help meeting attendance , and health care utilization . RESULTS At baseline , 63 % of participants reported their main drug was marijuana , 19 % cocaine , and 17 % opioids . At 6 months , 98 % completed follow-up . Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group ( incidence rate ratio [ IRR ] , 0.97 ; 95 % CI , 0.77 - 1.22 ) and 12 for the MOTIV group ( IRR , 1.05 ; 95 % CI , 0.84 - 1.32 ; P = .81 for both comparisons vs no brief intervention ) . There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity . CONCLUSIONS AND RELEVANCE Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening . These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00876941 OBJECTIVE : In the United States , 15- to 24-year-olds represent ∼14 % of HIV cases diagnosed in 2006 and almost 50 % of the 19 million sexually transmitted infections ( STIs ) reported annually . This survey assessed pediatricians ' practice s regarding preventive health care screening , provision of reproductive health services including HIV and STI screening and counseling , and barriers to providing these services . METHODS : A r and om- sample mailed survey of 1626 US members of the American Academy of Pediatrics in 2005.A total of 752 completed question naires were returned ( 46 % response rate ) . Analysis was limited to the 468 pediatricians who provided health supervision visits to patients who were older than 11 years . RESULTS : Most pediatricians discussed sexual activity at preventive care visits ; similar numbers discuss abstinence ( 62 % ) , condoms ( 61 % ) , and STIs ( 61 % ) with slightly fewer discussing HIV ( 54 % ) . Pediatricians occasionally or rarely/never discussed homosexuality/sexual identity ( 82 % ) . Most ( 71 % ) identified adolescents with high-risk behaviors by clinical interviews . Approximately 30 % prescribed condoms , 22 % distributed condoms , and 19 % provided condom demonstrations . Whereas 46 % of pediatricians recommended STI tests for all sexually active teens , only 28 % recommended HIV testing for this population . Hospital/clinic-based and inner-city practitioners were more likely to prescribe , provide , and demonstrate condoms and recommend HIV/STI tests for sexually active teens . The most frequently identified barrier to HIV and STI prevention counseling was lack of time . CONCLUSIONS : Pediatricians believed it is important to deliver reproductive health services , and most addressed adolescent sexual activity at preventive care visits but did not routinely address homosexuality/sexual identity . Counseling and testing practice s varied by physician characteristics Physicians often fail to provide nationally recommended preventive services for their patients . Addressing this , we have review ed selected literature on changing physician behavior using the organizational construct of the " readiness for change " transtheoretical model . This model suggests that behavior evolves through stages from precontemplation , to contemplation , to preparation , to initiation , and to maintenance of change . Traditional continuing medical education may affect knowledge and beliefs , but rarely results in behavior change . However , motivational strategies such as practice feedback reports and influential peers can foster stage change . Successful interventions aim ed at physicians preparing for change frequently use an office-system approach that targets not only physicians , but office staff and patients as well . Illustrating how the readiness to change model can guide the design and implementation of interventions , we describe strategies being used in a statewide r and omized controlled trial to improve cancer prevention counseling and early detection by primary care physicians . The multistage interventions of Partners for Prevention include support from a medical liability carrier , a motivational videotape , a task-delineated office manual , chart flowsheets , patient activation forms , practice feedback reports , a design ated prevention coordinator within each practice and regular telephone calls and office visits by project staff Breast cancer is the most common cancer type in women and the fourth leading cause of cancer death in the United States ( 1 ) . The goal of screening is to reduce morbidity and mortality , both specific to breast cancer and overall , with acceptable tradeoffs ( 2 , 3 ) . The most commonly used screening test is mammography . Recommended strategies vary for breast cancer screening in average-risk women . Ages to start and discontinue mammography , screening intervals , the role of imaging methods other than mammography , and the role of clinical breast examination ( CBE ) have been points of disagreement among guideline developers . Purpose and Target Population The goal of this American College of Physicians ( ACP ) guidance statement is to critically review selected guidelines from around the world and their included evidence to assist clinicians in making decisions about breast cancer screening in asymptomatic women with average risk for breast cancer . Included screening methods are CBE and breast imaging ( that is , mammography , ultrasonography , magnetic resonance imaging [ MRI ] , and digital breast tomo synthesis [ DBT ] ) . This guidance statement does not address breast self-examination because no evaluated guideline recommends it for screening . The target population for this guidance statement is women with average risk for breast cancer . The target audience is all clinicians . Age is the single most important risk factor for breast cancer . Included guidelines generally define average-risk women as those who do not have a personal history of breast cancer or a previous diagnosis of a high-risk breast lesion , are not at high risk for breast cancer due to genetic mutations known to increase that risk ( such as BRCA1/2 gene mutation or another familial breast cancer syndrome ) , and were not exposed to radiation therapy to the chest in childhood ( 4 , 5 ) . However , definitions of average risk vary among guidelines . In addition , although risk factors ( including early menarche , late menopausal onset , oral contraceptive or menopausal hormone therapy , increased breast density on mammography , and a family member with a history of postmenopausal breast cancer ) may put a woman at greater risk for breast cancer than women without these factors , the evaluated guidelines generally include women with these factors under the umbrella of average risk . Therefore , our guidance statement applies to these women . Guidelines vary somewhat in target population s and screening methods addressed ( Table [ 411 ] and Appendix ) . Both the U.S. Preventive Services Task Force ( USPSTF ) and the World Health Organization ( WHO ) include women with dense breasts and those with a single family member with breast cancer in their guideline 's target population ( 5 , 6 ) . The Canadian Task Force on Preventive Health Care ( CTFPHC ) guideline also includes women with dense breasts ; however , it explicitly mentions that women with a first-degree relative with breast cancer are considered to be at increased risk and are thus excluded from the guideline ( 7 ) . Table . Summary of Included Recommendations in Assessed Guidelines for Breast Cancer Screening of Average-Risk Women Methods The ACP Clinical Guidelines Committee develops guidance statements on topics where several conflicting guidelines are available . Guidance statements rely on evidence presented or referenced in selected guidelines and accompanying evidence reports ; they do not include de novo review s or search es of the literature outside the body of evidence referenced by the guidelines . The goal of ACP guidance statements is to provide clinicians with a rigorous review of the available guidelines and their included evidence and to develop subsequent guidance based on an assessment of the benefits and harms reported by each guideline and its evidence . Unlike ACP guidelines , guidance statements are not derived from a systematic evidence review and hence do not use GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) ( 12 ) to assess the quality of evidence or strength of recommendations . Data Sources and Guideline Selection We search ed the National Guideline Clearinghouse and the Guidelines International Network library for breast cancer screening guidelines from national organizations that addressed breast imaging ( that is , mammography , ultrasonography , MRI , or DBT ) and CBE in women and were published in English between 1 January 2013 and 15 November 2017 . We search ed Web sites housing the selected guidelines for up date s on 10 December 2018 . We excluded guidelines that addressed specific population s ( such as pregnant women and women at increased risk for breast cancer ) or were more than 5 years old ( thus considered inactive ) . We also excluded guidelines that directly endorsed another guideline , such as that of the American Academy of Family Physicians , which endorsed the USPSTF guideline . Our search yielded 3 guidelines , from the American College of Radiology ( published in 2017 ; literature search end date , February 2016 ) ( 9 ) , American Cancer Society ( ACS ) ( published in 2015 ; literature search end date , March 2014 ) ( 4 ) , and USPSTF ( published in 2016 ; literature search end date , June 2015 ) ( 5 ) . We also selected 3 guidelines not identified in either data base but commonly used in clinical practice , from the National Comprehensive Cancer Network ( NCCN ) ( published in 2018 ; literature search end date not reported ) ( 10 ) , WHO ( published in 2014 ; literature search end date , December 2012 ) ( 6 ) , and American College of Obstetricians and Gynecologists ( published in 2017 ; literature search end date not applicable ) ( 8) . In addition , we selected the CTFPHC guideline , which was up date d after our initial search ( published in 2018 ; literature search end date , January 2017 ) ( 7 ) . The American College of Obstetricians and Gynecologists guideline was based on guidelines from the ACS , NCCN , and USPSTF and supporting evidence review s. Critical Appraisal Five co authors independently review ed , assessed , and scored each guideline using the AGREE II ( Appraisal of Guidelines for Research and Evaluation II ) instrument ( 13 , 14 ) ( Appendix Table 1 ) . Appendix Table 1 . Scaled AGREE II Domain Scores for Each Guideline and Overall Assessment Clinician Peer Review The guidance statement was peer- review ed through Annals of Internal Medicine and by ACP Regents and Governors , who represent ACP members at the regional and international level . Public Member Review The development process for the guidance statement included participation by public members ( 2 of the Clinical Guidelines Committee and 7 of ACP 's Public Panel ) to share their perspectives , values , and preferences . Critical Appraisal of Evaluated Guidelines The major difference between high- and low-scoring guidelines ( Appendix Table 1 ) was methodology . Guidelines from ACS ( 4 ) , CTFPHC ( 7 ) , USPSTF ( 5 ) , and WHO ( 6 ) scored highest on the AGREE II instrument , whereas those from the American College of Obstetricians and Gynecologists ( 8) , American College of Radiology ( 9 ) , and NCCN ( 10 ) scored lowest . In addition to our review of each guideline , we examined the evidence supporting the 4 that scored highest ( ACS , CTFPHC , USPSTF , and WHO ) . We also considered recommendations for adoption or adaptation from these 4 guidelines when developing our own guidance . Several factors were important in considering guideline quality . The ACS , CTFPHC , USPSTF , and WHO guidelines best articulated benefits , harms , and strength of the evidence and how these link to recommendations . The lower-scoring guidelines often inadequately described how they considered these factors in developing the recommendations , or they relied on lower- quality evidence . The guidelines varied in the studies they reported , weighting of observational or modeling studies relative to r and omized controlled trials ( RCTs ) , and emphasis on relative versus absolute effects . The guidelines rarely addressed the small absolute effect on breast cancer mortality ; the long lead time to any reduction in this mortality , especially in women with estimated life expectancy less than 15 to 20 years ; and the low incidence of breast cancer for women younger than 60 years . Mammography Depending on the guideline , the recommended age to discuss initiating screening is 40 years ( 4 , 5 , 8) and the recommended age to start screening ranges from 40 ( 9 , 10 ) to 45 ( 4 ) to 50 ( 58 ) years . Most guidelines agree to screen average-risk women with  mammography  between ages 50 and 74 years . However , WHO and CTFPHC recommend that screening in women aged 50 to 69 years should include shared decision making because screening is conditional on a woman 's values and preferences . For women aged 70 to 75 years , WHO recommends screening only in the context of both rigorous research and shared decision making . Other areas of disagreement include screening in women aged 40 to 49 years , screening in women aged 75 years or older , and recommended screening intervals ( Table ) . Intervals range from annual ( particularly in women aged 40 to 49 years ) to biennial or triennial . Guidelines from ACS , USPSTF , and WHO conclude that a close balance exists between screening benefits and harms for women in their 40s ( for ACS , 40 to 44 years ) and that decisions are influenced by patient preferences . The WHO guideline suggests population -based screening programs in women aged 40 to 49 years only in the context of rigorous research , monitoring , and evaluation and if shared decision-making strategies are implemented . The CTFPHC conditionally recommends against screening in women aged 40 to 49 years ( without a first-degree family history of breast cancer ) ; however , it states that some women in this age group may wish to be screened and that clinicians should engage in shared decision making with women who express interest ( Appendix ) . Appendix Table 2 summarizes the available data from the 4 guidelines with the highest AGREE II scores ( ACS , CTFPHC , USPSTF , and WHO ) . Appendix Table 2 . Summary of Evidence on Screening BACKGROUND Cancer screening is one approach to reducing cancer-related morbidity and mortality rates .  Screening strategies vary in intensity . Higher-intensity strategies are not necessarily higher value . High-value strategies provide a degree of benefits that clearly justifies the harms and costs incurred ; low-value screening provides limited or no benefits to justify the harms and costs . When cancer screening leads to benefits , an optimal intensity of screening maximizes value . Some aspects of screening practice s , especially overuse and underuse , are low value . METHODS Screening strategies for asymptomatic , average-risk adults for 5 common types of cancer were evaluated by review ing clinical guidelines and evidence syntheses from the American College of Physicians ( ACP ) , U.S. Preventive Services Task Force , American Academy of Family Physicians , American Cancer Society , American Congress of Obstetricians and Gynecologists , American Gastroenterological Association , and American Urological Association . " High value " was defined as the lowest screening intensity threshold at which organizations agree about screening recommendations for each type of cancer and " low value " as agreement about not recommending overly intensive screening strategies . This information is supplemented with additional findings from r and omized , controlled trials ; modeling studies ; and studies of costs or re source use , including information found in the National Cancer Institute 's Physician Data Query and UpTo Date . The ACP provides high-value care screening advice for 5 common types of cancer ; the specifics are outlined in this article . The ACP strongly encourages clinicians to adopt a cancer screening strategy that focuses on reaching all eligible persons with these high-value screening options while reducing overly intensive , low-value screening BACKGROUND Educational interventions that support the implementation of complex clinical practice guidelines ( CPGs ) require substantial time commitments from participants . We conducted a comparative study to evaluate if a 90-minute workshop would increase compliance with the recommendations of the Canadian Task Force on Preventive Health Care as well as decrease the ordering of tests not the subject of specific recommendations . METHODS Eighty-seven family physicians from Quebec participated in the study . Group assignment was initially r and omized , but , owing to logistic problems , r and omization was not maintained . After unannounced visits , 2 st and ardized patients coded the physicians ' performance of 23 items recommended for inclusion in the periodic health examination ( 10 for men and 13 for women ) and 8 items recommended for exclusion ( 4 for both men and women ) . The " exposed " physicians were visited within 4 to 6 months after the workshop . The " nonexposed " physicians were visited within 4 to 6 months after consent was obtained but before they attended the workshop . We used linear regression analysis to determine if exposure to the workshop result ed in improved performance . RESULTS Exposure to the workshop was not associated with a difference in the adjusted mean score for items recommended for inclusion ( 12.07 for exposed physicians v. 12.35 for those not exposed ; maximal and ideal score 23 ; r = -0.28 ; 95 % confidence interval [ CI ] = -1.63 to 1.08 ) . However , workshop exposure was associated with lower adjusted mean scores for items recommended for exclusion ( 1.55 v. 3.17 ; maximal score 8 , ideal score 0 ; r = -1.63 ; 95 % CI = -2.50 to -0.75 ) and for other tests ( 3.59 v. 6.53 ; r = -2.95 ; 95 % CI = -5.10 to -0.79 ) . INTERPRETATION A short workshop can decrease the ordering of unnecessary screening tests by family physicians . Given its low cost and its potential for general application , such an intervention can support the implementation of prevention CPGs BACKGROUND In accordance with the U.S. Preventive Services Task Force recommendations , the current pilot study tests the feasibility and efficacy of a physician-delivered physical activity counseling intervention . METHODS A sequential comparison group design was used to examine change in self-reported physical activity between experimental ( counseling and self-help material s ) and control ( usual care ) patients at base-line and 6 weeks after the initial office visit . Patients in both groups were contacted by telephone 2 weeks after their office visit and asked about the physical activity counseling at their most recent physician visit . Experimental patients also received a follow-up appointment to discuss physical activity with their physician 4 weeks after their initial visit . RESULTS Counseling was feasible for physicians to do and produced short-term increases in physical activity levels . Both groups increased their physical activity , but the increase in physical activity was greater for patients who reported receiving a greater number of counseling messages . CONCLUSIONS Physician-delivered physical activity interventions may be an effective way to achieve wide-spread improvements in the physical activity of middle-aged and older adults BACKGROUND We conducted a r and omized clinical trial of interventions to achieve physician consensus , practice changes , and patient activation design ed to help primary care group practice s enhance the delivery of cancer prevention and screening services . METHODS In each of 42 primary care practice s in 1991 to 1994 , we studied approximately 60 patients per physician who were between the ages 53 and 64 . Data sources included  patient and physician question naires , medical record audits of consenting patients for evidence of 11 cancer prevention services during the previous 3 years , and telephone interviews with key practice personnel . RESULTS None of the interventions was associated with significant changes in frequency of services or procedures received or provided . Increased frequencies of services overall and of specific activities were associated with HMO membership or insurance coverage for six screening procedures . Patient reports of clinic staff recommendations to have each of six screening procedures were specifically associated with higher frequencies of services ( P = 0.001 ) . CONCLUSIONS Demonstration of intervention impact may have been limited because the rates of prevention services were significantly higher in this study than have been reported elsewhere . These results might be explained by selection biases inherent in study ing patients with a regular provider , overall practice trends for changes in provision of the studied services , and the study methods BACKGROUND Controversy exists regarding the optimal way to provide health promotion education to the elderly . This prospect i ve r and omized study evaluated the effectiveness of individualized assessment and counseling coupled with the receipt of a written health plan on client adherence to health behavior recommendations . METHODS Two hundred thirty-seven ethnically diverse and predominantly low-income adults 60 and older , participating for the first time in an established statewide public health prevention program delivered in both rural and urban clinics , were recruited and r and omly assigned to treatment and control groups . All participants received a st and ardized assessment that included a health history , nutrition assessment , and limited physical exam from a public health nurse . The treatment group additionally received a written personal health plan and individualized counseling to support implementation of the plan . Both groups were interviewed after one year to determine their adherence to the original recommendations . RESULTS Seventeen preventive services and health behaviors were evaluated . There were no statistically significant differences between the groups on health care use and previous health behaviors at baseline . Using logistic regression and controlling for socioeconomic and demographic variables , we found that the treatment group that received a personal health plan and counseling completed significantly more preventive referrals and health behavior changes ( P < .001 ) . CONCLUSIONS A client-centered planning process with supportive counseling by public health nurses , combined with health plans provided to clients , can significantly increase the prevention measures taken by older adults BACKGROUND The Health Education and Research Trial ( HEART ) was a multicenter clinical trial design ed to test methods to improve primary care practice systems for heart disease prevention services . We present the trial methodology , the practice s ' use of medical record tools , and changes in documentation of cardiovascular risk factor screening and management . METHODS Primary care practice s were recruited from 4 Midwestern states . The factorial design result ed in 4 study groups : conference only , conference and quality improvement consultations , conference and prevention coordinator , and all interventions combined .  Medical record audits and physician , staff , and patient surveys assessed practice change in cardiovascular disease risk factor documentation . RESULTS Practice s participated fully in this project , set goals to improve preventive services , and implemented recommended medical record tools . The number of goals set and the increase in the use of medical record tools were greatest in the combined intervention group , with improvements noted in all groups . The use of patient history question naires , problem lists , and flow sheets was significantly higher in the combined intervention group when compared with the conference-only group . Documentation of risk factor screening in a recommended-medical record location improved in all intervention groups , with significant sustained improvements in the practice s that received the combined intervention . Documented risk factor management significantly improved in all intervention groups compared with the conference-only control . CONCLUSION Primary care practice s are interested in improving prevention systems and can change these systems in response to supportive external interventions . Promoting organizational change to produce sustained improvement in preventive service clinical outcomes is a complex process that requires further research Purpose This study aims to provide recommendations on the optimal strategies and interventions for the prevention , screening , assessment , and management of  cancer-related sleep disturbance ( insomnia and insomnia syndrome ) in adult cancer population s. Methods A systematic search of the published health literature was conducted to identify r and omized controlled trials , clinical practice guidelines , systematic review s , and other guidance documents . The Sleep Disturbance Expert Panel [ comprised of nurses , psychologists , primary care physicians , oncologists , physicians specialized in sleep disturbances , research ers , and guideline method ologists ] review ed , discussed , and approved the final version of the guideline . Health care professionals across Canada were asked to provide feedback through an external review process . Results Three clinical practice guidelines and 12 r and omized controlled trials were identified as the evidence base . Overall , despite the paucity of evidence , the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using st and ardized screening tools on a routine basis . While prevention of sleep disturbance is the desired objective , cognitive behavioral therapies are effective in improving sleep outcomes . As part of the external review with 16 health care providers , 81 % indicated that they agreed with the recommendations as written . Conclusions Sleep difficulty is a prevalent problem in cancer population s that needs greater recognition by health professionals . Prevention , screening , assessment , and treatment strategies supported by the best available evidence are critical . Recommendations and care path algorithms for practice are offered Background There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical , psychological and social health of the population . There also exists a substantial evidence base for the efficacy of brief interventions aim ed at reducing alcohol consumption across a range of healthcare setting s. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness . Within this body of evidence there is marked variation in the intensity of brief intervention delivered , from very minimal interventions to more intensive behavioural or lifestyle counselling approaches . Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments . Methods / design The study design is a prospect i ve pragmatic factorial cluster r and omised controlled trial . Individual Emergency Departments ( ED ) ( n = 9 ) are r and omised with equal probability to a combination of screening tool ( M-SASQ vs FAST vs SIPS-PAT ) and an intervention ( Minimal intervention vs Brief advice vs Brief lifestyle counselling ) . The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker ( AHW ) is more effective than Brief Advice or a minimal intervention delivered by ED staff . Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED . Individual participants will be followed up at 6 and 12 months after consent . The primary outcome measure is performance using a gold-st and ard screening test ( AUDIT ) . Secondary outcomes include ; quantity and frequency of alcohol consumed , alcohol-related problems , motivation to change , health related quality of life and service utilisation . Discussion This paper presents a protocol for a large multi-centre pragmatic factorial cluster r and omised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments . Trial Registration IS RCT N OBJECTIVE To determine the rates at which private primary -care clinics are recommending blood pressure and cholesterol measurement , smoking cessation , clinical breast examination , screening mammography , Papanicolaou testing , and influenza and pneumococcus immunizations . MATERIAL AND METHODS We conducted a mail survey of 7,997 r and omly selected patients from 44 primary -care clinics in and around Minneapolis-St . Paul , Minnesota , of whom 6,830 ( 85.4 % ) completed the question naire on preventive services delivery rates . The responses were analyzed statistically , including stratification by reason for the clinic visit . RESULTS On the average , about two-thirds of the patients in each clinic reported being up-to- date on preventive services before their clinic visit ; an exception was pneumococcus immunization ( mean rate , 33 % ) . Except for blood pressure and smoking cessation advice , less than 30 % of patients who were not up-to- date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination . For patients who said that they saw their physician for a checkup or physical examination , the rate was more than 50 % only for Papanicolaou smear . In contrast , nearly all responding practitioners agreed that each of the eight preventive services was very important or important . CONCLUSION Preventive services consensus goals are not being met , even for patients who report that their clinic visit was for a checkup or physical examination . This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services BACKGROUND Screening mammography is recommended for early detection of breast cancer but screening rates remain suboptimal . METHODS A primary care portal for a large academic primary practice was developed for all preventive services . Another Web-based system ( PRECARES [ PREventive CAre REminder System ] ) was developed for appointment secretaries to manage proactive breast cancer screening . Female patients aged 40 to 75 years were r and omly assigned to a control group ( usual care ) and an intervention group . For the intervention group , 2 monthly letters inviting patients to undergo mammography were sent starting 3 months before they were due for annual screening , followed by a telephone call to nonresponding patients . A subgroup of women employees was further r and omized to receive a reminder by either US mail or e-mail . RESULTS Of the total eligible population of 6665 women identified as having consented to participate in research , 3339 were r and omly assigned to the control group and 3326 to the intervention group . The screening rate for annual mammography  was 64.3 % for the intervention group and 55.3 % for the control group ( P < .001 ) . There were no significant differences between the 2 groups for any of the other adult preventive services . For the employee subgroup , the screening rate was 57.5 % for the control group , 68.1 % for the US mail group , and 72.2 % for the e-mail group ( intervention vs control , P < .001 ; e-mail vs US mail ; P = .24 ) . CONCLUSION The breast cancer screening rate improved significantly with the practice re design of having appointment secretaries proactively manage breast cancer screening needs Background Primary care provides most of the evidence -based chronic disease prevention and screening services offered by the healthcare system . However , there remains a gap between recommended preventive services and actual practice . This trial ( the BETTER Trial ) aim ed to improve preventive care of heart disease , diabetes , colorectal , breast and cervical cancers , and relevant lifestyle factors through a practice facilitation intervention set in primary care . Methods Pragmatic two-way factorial cluster RCT with Primary Care Physicians ’ practice s as the unit of allocation and individual patients as the unit of analysis . The setting was urban Primary Care Team practice s in two Canadian provinces . Eight Primary Care Team practice s were r and omly assigned to receive the practice -level intervention or wait-list control ;  4 physicians in each team ( 32 physicians ) were r and omly assigned to receive the patient-level intervention or wait-list control .  Patients r and omly selected from physicians ’ rosters were stratified into two groups : 1 ) general and 2 ) moderate mental illness . The interventions involved a multifaceted , evidence -based , tailored practice -level intervention with a Practice Facilitator , and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored ‘ prevention prescription ’ . The primary outcome was a composite Summary Quality Index of 28 evidence -based chronic disease prevention and screening actions with pre-defined targets , expressed as the ratio of eligible actions at baseline that were met at follow-up . A cost-effectiveness analysis was conducted . Results 789 of 1,260 ( 63 % ) eligible patients participated . On average , patients were eligible for 8.96 ( SD 3.2 ) actions at baseline . In the adjusted analysis , control patients met 23.1 % ( 95 % CI : 19.2 % to 27.1 % ) of target actions , compared to 28.5 % ( 95 % CI : 20.9 % to 36.0 % ) receiving the practice -level intervention , 55.6 % ( 95 % CI : 49.0 % to 62.1 % ) receiving the patient-level intervention , and 58.9 % ( 95 % CI : 54.7 % to 63.1 % ) receiving both practice - and patient-level interventions ( patient-level intervention versus control , P < 0.001 ) . The benefit of the patient-level intervention was seen in both strata . The extra cost of the intervention was $ 26.43CAN ( 95 % CI : $ 16 to $ 44 ) per additional action met . Conclusions A Prevention Practitioner can improve the implementation of clinical ly important prevention and screening for chronic diseases in a cost-effective manner Physicians endorse prevention but provide only low levels of screening , health counseling , and immunization . Between 1981 and 1986 , a r and omized controlled trial was conducted at the Seattle ( Wash ) Veterans Affairs Medical Center to assess the effectiveness of the following three methods of delivery of preventive services : ( 1 ) a physician-oriented model that includes education and motivation , a chart flowsheet listing recommended activities , and periodic feedback about performance ; ( 2 ) a patient education model in which patients were mailed an informative brochure advising them to ask physicians for preventive services as depicted in a patient-held pocket guide ; and ( 3 ) a health promotion clinic that patients were invited to attend . A control group received their usual care .  A total of 1224 male out patients were enrolled in the trial .  Baseline prevention rates for 12 age-specific prevention activities were below 25 % . Neither the control group rates during the 5-year trial nor the rates for the two educational models , either singly or as a combined intervention , changed . Only the health promotion clinic model was effective , tripling prevention rates in its first year and sustaining these levels for all 5 years . It is difficult to change the clinic roles of experienced physicians and their long-term patients in a specialized multiclinic setting . Providing a separate health promotion clinic option is popular with patients , bypasses gatekeeper barriers , is reasonable in cost , and warrants wider application Background . Colorectal cancer is the second leading cause of cancer-related death in the United States . Despite universal screening recommendations , screening rates in the United States remain suboptimal , especially among the poor , the uninsured , recent immigrants , and Hispanics . This article describes the development of a large community-based colorectal cancer screening program design ed to address these disparities . Method . The Against Colorectal Cancer in our Neighborhoods program is a bilingual , evidence -based , theory-guided , multicomponent community screening intervention , targeting the uninsured and developed using a systematic planning process . It combines community health worker – led outreach , bilingual and culturally tailored community education , and no-cost screening with provision of the fecal immunochemical test or colonoscopy and navigation services . A detailed process and outcome evaluation is planned . Program development cost calculated prospect ively ( in 2011 dollars ) using a societal perspective and micro-costing methods was $ 243,278 , of which $ 180,344 was direct cost . Discussion . The detailed description of the development processes and costs of this health promotion program targeting low-income Hispanics will inform health program decision makers about the re source requirements for planning and developing new programs to reduce disease burden in communities Cardiovascular disease remains the leading cause of death in women . Both obesity and diabetes mellitus are important independent risk factors for the development of cardiovascular disease . Obesity is the leading risk factor for type 2 diabetes . The Centers for Disease Control and Prevention report that 32 % of white and 53 % of black women are obese . Women with a body mass index ( BMI ) of 30 kg/m2 have a 28 times greater risk of developing diabetes than do women of normal weight . The risk of diabetes is 93 times greater if the BMI is 35 kg/m2.1 The presence of diabetes can increase a woman 's risk of heart disease 2-fold . In addition , the presence of diabetes overshadows the protective effects of the premenopausal state . In 2007 , 11.5 million of all women over the age of 20 ( 10.2 % ) had diabetes , and rates were slightly higher in ethnic minority groups : 10.4 % in Hispanic women and 11.8 % in non-Hispanic black women.2 The national prevalence rates of diabetes have increased in parallel with the rates of obesity ( Fig. 1 ) . Fig. 1 Age-adjusted percentage of U.S. adults who were obese or who had a diagnosis of diabetes mellitus . Screening Screening for obesity and diabetes is the 1st step to treatment and often reveals individuals who are at risk for but do not yet have overt disease . The United States Preventive Services Task Force ( USPSTF ) recommends that all adults be screened for obesity . Obesity signifies excess adipose tissue . The most widely used method for screening is determination of the BMI . The BMI is weight in kilograms divided by height in meters squared ( BMI = kg/m2 ) ( Table I ) . Most electronic medical records automatically calculate BMI if height and weight are entered . There are also many smart-phone applications and online calculators that can calculate BMI ( for example , http://www.nhlbisupport.com/ bmi ) . Other screening tools include  waist circumference and the waist-to-hip ratio . In women , a waist circumference > 35 in ( 88 cm ) or a waist-to-hip ratio > 0.7 indicates excess visceral fat and increased risk for disease . TABLE I. Body Mass Index ( BMI ) Classification Recommendations for screening for diabetes vary by guideline author . The USPSTF recommends screening asymptomatic patients who have  blood pressures > 135/80 mmHg  . The American Diabetes Association ( ADA ) recommends that individuals who are ≥18 years of age and have a BMI ≥25 kg/m2 and 1 additional risk factor for diabetes should be screened annually ( Table II).3 Individuals over the age of 45 without risk factors should be screened every 3 years . In January 2010 , the ADA released new recommendations for the use of hemoglobin A1C as a screening tool . An A1C greater than 6.5 % indicates diabetes . In addition , the results of screening tests for diabetes can identify individuals with “ prediabetes ” who have a markedly increased risk of developing overt disease.3 TABLE II . American Diabetes Association Recommendations on Screening for Type 2 Diabetes3 Non-Pharmaceutical Treatment Lifestyle-treatment options for diabetes mellitus and excess weight are similar , and 2 recent studies 4,5 have demonstrated the critical components for treating pre-diabetes and diabetes through weight loss , using caloric restriction and physical activity . The 1st study was the Diabetes Prevention Program.4 The purpose of the study was to identify individuals who were at risk for developing diabetes because of elevated fasting plasma glucose or impaired glucose tolerance levels that were not yet in the diagnostic range , in order to determine if metformin or an intensive lifestyle intervention could delay or prevent the onset of diabetes . More than 3,000 individuals with prediabetes were r and omized to receive placebo , metformin , or a 16-session lifestyle-modification program . The intensive lifestyle program set a goal of 7 % weight loss and 150 min/wk of moderate physical activity . Fifty percent of the lifestyle-intervention group lost 7 % of their body weight . The 3-year incidence of diabetes in the metformin group was 31 % lower than that in the placebo group . The incidence was 58 % lower in the lifestyle group than in the placebo group.4 The clinical implication s of this study are that we should 1 ) identify individuals with pre-diabetes and 2 ) recommend lifestyle modifications that result in a 7 % weight loss and include 150 min/wk of moderate physical activity . The 2nd study that examined lifestyle treatment of diabetes and obesity is the Look AHEAD Trial . The purpose of the study was to determine the effect of intentional weight loss on cardiovascular risk factors in individuals with diabetes . Approximately 5,100 individuals with type 2 diabetes and an elevated BMI were r and omized . Study conditions specified a 36-session intensive lifestyle intervention with the option of using partial meal replacements for caloric restriction or 4 sessions of st and ard diabetes support and education ( DSE ) . At 1 year , 55 % of the intensive-lifestyle-intervention group achieved 7 % weight loss . Hemoglobin A1C , systolic and diastolic blood pressure , and lipids improved significantly more in the intensive-lifestyle group than in the DSE group.5 The clinical implication of this study is that intentional weight loss of at least 7 % can improve the cardiovascular risk profile of patients with type 2 diabetes . Conclusions Excess weight affects two thirds of the U.S. adult population and increases risk for cardiovascular disease and diabetes . All patients should be screened for obesity and most should be screened for pre-diabetes and diabetes . The best treatment for diabetes is prevention . Prevention of diabetes can be accomplished through a 7 % weight loss through intensive lifestyle interventions that include caloric reduction and approximately 30 min of daily moderate physical activity . Practitioners will have access to these evidence -based programs soon . The Centers for Disease Control and Prevention are promoting community-based diabetes prevention programs throughout the country Background : The US Preventive Services Task Force recently recommended against prostate-specific antigen screening for prostate cancer based primarily on evidence from the European R and omized Study of Screening for Prostate Cancer ( ERSPC ) and the US Prostate , Lung , Colorectal , and Ovarian ( PLCO ) cancer screening trial . Objective : To examine limitations of basing screening policy on evidence from screening trials . Methods : We review ed published modeling studies that examined population and trial data . The studies ( 1 ) project the roles of screening and changes in primary treatment in the US mortality decline ; ( 2 ) extrapolate the ERSPC mortality reduction to the long-term US setting ; ( 3 ) estimate overdiagnosis based on US incidence trends ; and ( 4 ) quantify the impact of control arm screening on PLCO mortality results . Results : Screening plausibly explains 45 % and changes in primary treatment can explain 33 % of the US prostate cancer mortality decline . Extrapolating the ERSPC results to the long-term US setting implies an absolute mortality reduction at least 5 times greater than that observed in the trial . Approximately 28 % of screen-detected cases are overdiagnosed in the United States versus 58 % of screen-detected cases suggested by the ERSPC results . Control arm screening can explain the null result in the PLCO trial . Conclusions : Modeling studies indicate that population trends and trial results extended to the long-term population setting are consistent with greater benefit of prostate-specific antigen screening— and more favorable harm-benefit tradeoffs — than has been suggested by empirical trial evidence BACKGROUND Most expert groups recommend shared decision making for prostate cancer screening . Most primary care physicians , however , routinely order a prostate-specific antigen ( PSA ) test with little or no discussion about whether they believe the potential benefits justify the risk of harm . We sought to assess whether educating primary care physicians and activating their patients to ask about prostate cancer screening had a synergistic effect on shared decision making , rates and types of discussion s about prostate cancer screening , and the physician ’s final recommendations . METHODS Our study was a cluster r and omized controlled trial among primary care physicians and their patients , comparing usual education ( control ) , with physician education alone ( MD-Ed ) , and with physician education and patient activation ( MD-Ed+A ) .  Participants included 120 physicians in 5 group practice s , and 712 male patients aged 50 to 75 years . The interventions comprised a Web-based educational program for all intervention physicians and MD-Ed+A patients compared with usual education ( brochures from the Centers for Disease Control and Prevention ) . The primary outcome measure was patients ’ reported postvisit shared decision making regarding prostate cancer screening ; secondary measures included unannounced st and ardized patients ’ reported shared decision making and the physician ’s recommendation for prostate cancer screening . RESULTS Patients ’ ratings of shared decision making were moderate and did not differ between groups . MD-Ed+A patients reported that physicians had higher prostate cancer screening discussion rates ( MD-Ed+A = 65 % , MD-Ed = 41 % , control=38 % ; P < .01 ) . St and ardized patients reported that physicians seeing MD-Ed+A patients were more neutral during prostate cancer screening recommendations ( MD-Ed+A=50 % , MD-Ed=33 % , control=15 % ; P < .05 ) . Of the male patients , 80 % had had previous PSA tests . CONCLUSIONS Although activating physicians and patients did not lead to significant changes in all aspects of physician attitudes and behaviors that we studied , interventions that involved physicians did have a large effect on their attitudes toward screening and in the discussion s they had with patients , including their being more likely than control physicians to engage in prostate cancer screening discussion s and more likely to be neutral in their final recommendations
Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving .
CONCLUSIONS These results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using st and ardized methods .
BACKGROUND The U.S. Preventive Services Task Force ( USPSTF ) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse .
This study was design ed to develop a st and ardized rating for the clinical ly preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services .