Recommendations from the U.S. Preventive Services Task
Force: A Roadmap for Behavioral Medicine and Public
Health (and some missing landmarks)
Ned Calonge, M.D., M.P.H.Chair, USPSTF
Objectives
Discuss: Structure of the Task Force Methods of the Task Force Behavioral medicine recommendations Missing landmarks
Behavior and prevention “Another major contribution of the Guide is its
emphasis on personal behavior and therefore behavioral counseling. Behavior and health are strongly linked. Improved control of behavioral risk factors, such as use of tobacco, alcohol, and other drugs, lack of exercise, and poor nutrition, could prevent half of premature deaths, one-third of all cases of acute disability, and half of all cases of chronic disability. It is extraordinarily important that physicians and other providers educate their patients about these matters.”
Edward N Brandt, Jr, M.D., Ph.D in the Foreword, Guide to Clinical Preventive Services, USPSTF, 1989
Challenges for prevention Most important messages about prevention
may not be getting through Not everything that might work does work Many potential services, limited clinical time Effective behavior change interventions need
additional support outside of traditional health systems
Services should be supported by good evidence before they are widely recommended
The U.S. Preventive Services Task Force
(USPSTF) Independent panel of nationally recognized,
non-federal researchers experienced in primary care, prevention, evidence-based medicine, and research methods
Member disciplines: family medicine, internal medicine/geriatrics, preventive medicine, pediatrics/adolescent medicine, Ob/Gyn, nursing, counseling/behavioral medicine, public health, and health policy
The U.S. Preventive Services Task Force
(USPSTF) Charged by Congress to:
» review the scientific evidence for clinical preventive services and
» develop evidence-based recommendations for the health care community
The U.S. Preventive Services Task Force
(USPSTF) Convened and supported by the Agency for
Health Research and Quality (AHRQ) Works with Evidence-based Practice
Centers (EPCs) to conduct rigorous, impartial assessments of scientific evidence
USPSTF recommendations are considered by many to be the gold standard for clinical preventive services
AHRQ Support of USPSTF
AHRQ
USPSTF
EPC
Contract to synthesizeevidence
Evidencepresented
Convenes RecommendationsAnalyticframeworkdevelopment
Steps in explicit process Define question and outcomes of interest
within an analytic framework Define and retrieve relevant evidence Evaluate QUALITY of individual studies Synthesize and judge STRENGTH of
available evidence Determine balance of benefits and harms Link recommendation to judgment about
net benefits
Analytic framework There are very few screening studies that
look at the primary question of screening efficacy in decreasing mortality
There are very few counseling studies that link the behavior change intervention with long-term health effects
Evidence-based reviews, focusing on RCTs, can put together a chain of evidence on which to base over-arching recommendations
Analytic framework for screening for a disease
Counseling topics—1st and 2nd Task Force methods
Counseling was recommended if there was evidence that changing the behavior would improve health outcomes, or even if the presence of the behavior was associated with increased risk compared with the absence of the behavior
Counseling topics—methodology changes of
current Task Force Based on analytic framework for screening Uses two interrelated analytic frameworks:
» Does changing individual health behavior improve health outcomes?
» Can interventions in the clinical setting influence people to change their behavior?
Raises the bar for counseling interventions to that equivalent for other preventive services
Does changing individual health behavior improve
health outcomes?
Can interventions in the clinical setting influence people to
change their behavior?
Grades of Recommendation
Estimate of Net Benefit (Benefit Minus Harms) Strength of
Overall Evidence of Effectiveness
Substantial Moderate Small Zero/Negative
Good A B C D Fair B B C D Poor I – Insufficient Evidence
Wording of recommendations
A - Strongly recommendbenefits substantially outweigh harmsB - Recommendbenefits outweigh harmsC - USPSTF makes no recommendation benefits and harms closely balancedD - Recommend against routine useineffective interventions or harms outweigh potential
benefits
The I letter grade Insufficient Evidence to Recommend for or
against the interventionCommon reasons: Lack of evidence on clinical outcomes Poor quality of existing studies Good quality studies with conflicting results
Possibility of clinically important benefits but more research needed to show the benefits
Reasons for Conflicting Recommendations
Evidence-based vs. consensus process Clinical vs. intermediate outcomes Consideration of possible harms Effectiveness vs. efficacy
» ideal setting vs. real world Primary care vs. specialty perspective Approach to uncertainty
» “do no harm”
Recent recommended services
Abd. aortic aneurysm B Alcohol B Aspirin for CVD A Blood pressure A Breast cancer B Cervical cancer A,D Chlamydial infection A,B Colorectal cancer A
Depression B Diabetes I,B Diet B Lipids A,B Obesity B Osteoporosis B Tobacco Use A
Recent ratings for behavioral counseling—A&B recommendations
Tobacco use (A) Alcohol use (B) Breastfeeding (B) Healthy diet in high risk adults (B)
Recent ratings for behavioral counseling—I
recommendations Prevent skin cancer Prevent low back pain Healthy diet in average risk adults Physical activity Vitamin supplementation to prevent
CVD and cancer (I on the basis of insufficient evidence that vitamins reduce the risk, not based on counseling)
Recent ratings for screening related to
behavior change Screening for depression (B, I) Screening for obesity in adults (B, I) Screening for family violence (I) Screening for suicide risk (I)
Recommendations not updated since 1996
Prevent HIV infection Prevent household and recreational injuries Prevent motor vehicle injuries Prevent youth violence Prevent unintentional pregnancy
Example: Screening for Alcohol Misuse
The Task Force focused on screening for risky and harmful alcohol use
Risky drinkers are “At risk from exceeding daily, weekly or per occasion thresholds”
Harmful drinkers “Exhibit physical, social or psychological harm, but may not meet criteria for dependence”
Fiellin et al. Screening for Alcohol Problems in Primary Care. Arch Intern Med, 2000
Analytic FrameworkAnalytic Framework
Adolescents-Females-Males
Adults-Females-Males
Women of Childbearing Age-Pregnant
Clinical Population
Harmful/At-RiskAlcohol Users
AdverseEffects Health Care
Utilization, Sick Days, Costs)
INTERVENTION (with or without follow-up)
4
AdverseEffects
Measures of Lower Risk Alcohol Use
Reduction in All-Cause
Mortality,Alcohol-Related Deaths,
AccidentsInjuries
Health CareSystem
Influences
ASSESSMENT2
1
Seniors (65+)-Females-Males
5
63
7
KQ4: Do BCIs reduce risky/harmful alcohol use in adults?
Average Consumption (11 fair-good quality RCTs and 1 fair quality CCT)
5 studies tested Brief interventions (single contact< 15 minutes)» 4/5 showed no effect on mean alcohol (drinks/week)
7 studies tested Brief Multi-contact interventions» 5/7 significantly reduced mean alcohol consumption» 1 study reports maintenance of reduced alcohol
consumption after 4 years
Overall evidence: GOOD
Net Reduction in Mean Drinks/Week (Control Group Change – Intervention Group Change)
-15 -10 -5 0 5
Wallace 1988, women (S)
Wallace 1988, men (S)
Ockene 1999, women (6 mos.) (S)
Ockene 1999, men (6 mos.) (S)
Ockene 1999, total (6 mos.) (S)
Fleming 1997, women (S)
Fleming 1997, men (S)
Fleming 1997, total (S)
Fleming 1999 (S)
Maisto, 2002, brief advice (S)
Curry, in press (NS)
Scott & Anderson, 1990, women (NS)
Anderson & Scott, 1992, men (S)
KQ4: Do BCIs reduce risky/harmful alcohol use in adults?
Proportion reporting binge use (6 RCTs)
In Brief and Brief Multicontact intervention groups, 3/6 studies showed decrease in binge drinking in treatment group
Large proportions of interventions and controls report binge use after intervention
Overall evidence: FAIR-GOOD
KQ4: Do BCIs reduce risky/harmful alcohol use in adults?
Proportion reporting safe/recommended use levels (10 fair-good RCTs)
In Brief and Brief Multicontact intervention studies, 7/10 studies, more intervention participants than controls achieved recommended or safe drinking levels.
Overall evidence: GOOD
Clinical/net benefit summary in adults
No evidence on harms-assumed to be small/zero
Adults receiving brief multi-contact intervention reduce their drinking 3.5-5.0 drinks/week more than controls (10-25% net reduction in drinking)
Binge use is less commonly reduced and remains prevalent (25-50%)
10-18% more intervention participants reported recommended or safe drinking
Alcohol Misuse – Screening and Behavioral Counseling
The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. B Recommendation
Alcohol Misuse – Screening and Behavioral Counseling
Rationale for B Recommendation
The USPSTF found good evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality, and good evidence that brief behavioral counseling interventions with followup produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer.
Alcohol Misuse – Screening and Behavioral Counseling
Rationale for B Recommendation cont. The USPSTF found some evidence that interventions lead to positive health outcomes 4 or more years post-intervention, but found limited evidence that screening and behavioral counseling reduce alcohol-related morbidity. The evidence on the effectiveness of counseling to reduce alcohol consumption during pregnancy is limited; however, studies in the general adult population show that behavioral counseling interventions are effective among women of childbearing age. The USPSTF concluded that the benefits of behavioral counseling interventions to reduce alcohol misuse by adults outweigh any potential harms.
Missing landmarks Often counseling interventions studies
don’t look at long term health outcomes, nor long term behavior change
There are few studies that provide evidence on the optimal approach to counseling in the primary care setting
There is very little data on potential harms of counseling
Healthy diet for average risk people
The USPSTF found fair evidence that brief, low- to medium-intensity behavioral dietary counseling in the primary care setting can produce small-to-medium changes in average daily intake of core components of an overall healthy diet (especially saturated fat and fruit and vegetables) in unselected patients.
The strength of this evidence, however, is limited by reliance on self-reported diet outcomes, limited use of measures corroborating reported changes in diet, limited followup data beyond 6 to 12 months, and enrollment of study participants who may not be fully representative of primary care patients.
Healthy diet (cont.) In addition, there is limited evidence to
assess possible harms. As a result, the USPSTF concluded that
there is insufficient evidence to determine the significance and magnitude of the benefit of routine counseling to promote a healthy diet in adults.
Physical Activity The USPSTF reviewed only the literature
on the effectiveness of primary care counseling to promote physical activity.
The USPSTF found insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity among adult patients.
Physical Activity (cont.) Controlled trials of physical activity counseling
in adult primary care patients were of variable quality and had mixed results.
Data on the feasibility and potential harms of routine physical activity counseling in primary care settings are limited.
As a result, the USPSTF could not determine the balance of potential benefits and harms of routine counseling to promote physical activity in adults.
Screening for family/intimate partner
violence 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.
Screening for family/intimate partner
violence (cont.) 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.
Other missing landmarks—public health
Most effective behavior change interventions require linkage to services outside the traditional health care system
For public health impact, services need to be available at the community level
Translation of behavioral change research into effective practice has additional challenges of:» Workforce capacity» Resources/funding» Integration with health care, other social systems
Filling in the gaps It’s difficult to justify a positive
recommendation when you can’t join all the links in the chain of evidence
Trials are essential to the evidence for behavioral interventions
Remember that an I recommendation is a call for research—it is not a conclusion that the intervention is not effective
Filling in the gaps Can you accurately detect the behavior? Does the intervention change the behavior?
» What are the key components?» What is the feasibility of implementation?
Is the behavior change sustained? Does the behavior change result in
improvements in health outcomes, or at least in intermediate outcomes (and is there a good link between intermediate outcomes and health outcomes?
Thanks to… Janelle Guirguis-Blake, MD (AHRQ) Gurvaneet Randhawa, MD (AHRQ) Russ Harris, MD (UNC) Evelyn Whitlock, MD (Oregon EPC)
www.preventiveservices.ahrq.gov
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