Guide to Clinical Preventive Services, 2008

Injury and Violence

Screening for Family and Intimate Partner Violence

Summary of 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. Grade: I Statement.

This USPSTF recommendation was first published in:  Ann Intern Med 2004;140(5):382-6.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/famviolence/famviolrs.htm.

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 (e.g., 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, nonwhite 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 (e.g., the HITS [Hurt, Insulted, Threatened, Screamed at] instrument, the Partner Abuse Interview, and the Women's Experience with Battering [WEB] Scale), none have been validated against measurable outcomes. Only a few screening instruments (the Caregiver Abuse Screen [CASE] and the Hwalek-Sengstock Elder Abuse Screening Test [HSEAST]) have been developed to identify potential older victims of abuse or their abusive caretakers. Both of these tools correlated well with previously validated instruments when administered in the community, but have not been tested in the primary care clinical setting.²⁰
• 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.

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Counseling About Proper Use of Motor Vehicle Occupant Restraints and Avoidance of Alcohol Use While Driving

Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the incremental benefit, beyond the efficacy of legislation and community-based interventions, of counseling in the primary care setting, in improving rates of proper use of motor vehicle occupant restraints (child safety seats, booster seats, and lap-and-shoulder belts). Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine counseling of all patients in the primary care setting to reduce driving while under the influence of alcohol or riding with drivers who are alcohol-impaired. Grade: I Statement.

This USPSTF recommendationwas first published in: Ann Intern Med. 2007;147:187-93.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspsmvin.htm

Clinical Considerations

• This recommendation refers to behavioral counseling interventions performed in the primary care setting, addressing parents of all infants and children, children, adolescents, and adults.
  
• The injury prevention benefits of child safety seat and booster seat use require proper use. (That is, the seats should be age- and weight-appropriate and should be installed and placed into the vehicle correctly.) Infants younger than 1 year of age and weighing fewer than 20 pounds should be placed in rear-facing, infant-only car safety seats or convertible seats positioned in the back seat. Infants younger than 1 year of age and weighing between 20 and 35 pounds should be placed in rear-facing convertible seats positioned in the back seat. Rear-facing child safety seats must not be placed in the front passenger seat of any vehicle that is equipped with an airbag on the front passenger side. Death or serious injury can result from the impact of the airbag against the child safety seat. Toddlers 1 to 4 years of age weighing 20 to 40 pounds should be restrained in a forward-facing convertible seat or forward-facing-only seat positioned in the back seat. Young children 4 to 8 years of age and up to 4’9” (57 inches) in height should be placed in a booster seat in the back seat. After this age (or height), lap-and-shoulder belt use is appropriate. Children younger than 13 years of age should sit in the back seat with lap-and-shoulder belts.
• Behavioral counseling interventions that include an educational component, as well as a demonstration of use or a distribution component, are more effective than those that include education alone.
  
• Clinical counseling in conjunction with community-based interventions has been effective in increasing proper use of child safety seats. Over the past decade, legislation and enforcement have contributed substantially to the increasing trends in child safety seat and seat belt use. A comprehensive strategy that includes community-based interventions, primary care counseling in the primary care setting, legislation, and enforcement is critical to the improvement of proper safety restraint use and decrease in the incidence of MVOI.

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Mental Health Conditions and Substance Abuse

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings. Grade: B Recommendation. The USPSTF concludes that the evidence is insufficient to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings. Grade: I Statement.

This USPSTF recommendation was first published in:  Ann Intern Med 2004;140:555-7.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htm.

Clinical Considerations

• Alcohol misuse includes "risky/hazardous" and "harmful" drinking that places individuals at risk for future problems. "Risky" or "hazardous" drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. "Harmful drinking" describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence.^21,22 Alcohol abuse and dependence are associated with repeated negative physical, psychological, and social effects from alcohol.²³ The USPSTF did not evaluate the effectiveness of interventions for alcohol dependence because the benefits of these interventions are well established and referral or specialty treatment is recommended for those meeting the diagnostic criteria for dependence.
• Light to moderate alcohol consumption in middle-aged or older adults has been associated with some health benefits, such as reduced risk for coronary heart disease.²⁴ Moderate drinking has been defined as 2 standard drinks (e.g., 12 ounces of beer) or less per day for men and 1 drink or less per day for women and persons older than 65,²⁵ but recent data suggest comparable benefits from as little as 1 drink 3 to 4 times a week.²⁶
• The Alcohol Use Disorders Identification Test (AUDIT) is the most studied screening tool for detecting alcohol-related problems in primary care settings. It is sensitive for detecting alcohol misuse and abuse or dependence and can be used alone or embedded in broader health risk or lifestyle assessments.^27,28 The 4-item CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is the most popular screening test for detecting alcohol abuse or dependence in primary care.²⁹ The TWEAK, a 5-item scale, and the T-ACE are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy.³⁰ Clinicians can choose screening strategies that are appropriate for their clinical population and setting.^28,31-34 Screening tools are available at the National Institute on Alcohol Abuse and Alcoholism Web site: www.niaaa.nih.gov.
• Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and followup. Multi-contact interventions for patients ranging widely in age (12-75 years) are shown to reduce mean alcohol consumption by 3 to 9 drinks per week, with effects lasting up to 6 to 12 months after the intervention. They can be delivered wholly or in part in the primary care setting, and by one or more members of the health care team, including physician and non-physician practitioners. Resources that help clinicians deliver effective interventions include brief provider training or access to specially trained primary care practitioners or health educators, and the presence of office-level systems supports (prompts, reminders, counseling algorithms, and patient education materials).
• Primary care screening and behavioral counseling interventions for alcohol misuse can be described with reference to the 5-As behavioral counseling framework: assess alcohol consumption with a brief screening tool followed by clinical assessment as needed; advise patients to reduce alcohol consumption to moderate levels; agree on individual goals for reducing alcohol use or abstinence (if indicated); assist patients with acquiring the motivations, self-help skills, or supports needed for behavior change; and arrange followup support and repeated counseling, including referring dependent drinkers for specialty treatment.³⁵ Common practices that complement this framework include motivational interviewing,³⁶ the 5 Rs used to treat tobacco use,³⁷ and assessing readiness to change.³⁸
• The optimal interval for screening and intervention is unknown. Patients with past alcohol problems, young adults, and other high-risk groups (e.g., smokers) may benefit most from frequent screening.
• All pregnant women and women contemplating pregnancy should be informed of the harmful effects of alcohol on the fetus. Safe levels of alcohol consumption during pregnancy are not known; therefore, pregnant women are advised to abstain from drinking alcohol. More research into the efficacy of primary care screening and behavioral intervention for alcohol misuse among pregnant women is needed.
• The benefits of behavioral intervention for preventing or reducing alcohol misuse in adolescents are not known. The CRAFFT questionnaire was recently validated for screening adolescents for substance abuse in the primary care setting.³⁹ The benefits of screening this population will need to be evaluated as more effective interventions become available in the primary care setting.

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Screening for Dementia

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. Grade: I Statement.

This USPSTF recommendation was first published in:  Ann Intern Med 2003;138:925-926.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/dementia/dementrr.htm.

Clinical Considerations

• The Mini-Mental Status Examination (MMSE) is the best-studied instrument for screening for cognitive impairment. When the MMSE is used to screen unselected patients, the predictive value of a positive result is only fair. The accuracy of the MMSE depends upon a person's age and educational level: using an arbitrary cut-point may potentially lead to more false-positives among older people with lower educational levels, and more false-negatives among younger people with higher educational levels. Tests that assess functional limitations rather than cognitive impairment, such as the Functional Activities Questionnaire (FAQ), can detect dementia with sensitivity and specificity comparable to that of the MMSE.
• Early recognition of cognitive impairment, in addition to helping make diagnostic and treatment decisions, allows clinicians to anticipate problems the patients may have in understanding and adhering to recommended therapy. This information may also be useful to the patient's caregiver(s) and family member(s) in helping to anticipate and plan for future problems that may develop as a result of progression of cognitive impairment.
• Although current evidence does not support routine screening of patients in whom cognitive impairment is not otherwise suspected, clinicians should assess cognitive function whenever cognitive impairment or deterioration is suspected, based on direct observation, patient report, or concerns raised by family members, friends, or caretakers.

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Screening for Depression

Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup. Grade: B Recommendation. The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression. Grade: I Statement.

This USPSTF recommendation was first published in:  Ann Intern Med 2002;136:760-4.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/depression/depressrr.htm.

Clinical Considerations

• Many formal screening tools are available (e.g., the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CES-D]).⁴⁰ Asking 2 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.⁴¹ 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 standard diagnostic criteria (i.e., those from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]) to determine the presence or absence of specific depressive disorders, such as major depression and/or dysthymia.⁴² The severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse) should be addressed.
• Many risk factors for depression (e.g., female sex, family history of depression, unemployment, and chronic disease) are common, but the presence of risk factors alone cannot 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 (e.g., panic disorder or generalized anxiety), substance abuse, or chronic pain.
• Clinical practices that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment, and careful followup. Benefits from screening are unlikely to be realized unless such systems are functioning well.
• Treatment may include antidepressants or specific psychotherapeutic approaches (e.g., cognitive behavioral 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 populations in primary care settings. 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 care-based interventions for depression in this age group is limited.

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Screening for Illicit Drug Use

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. Grade: I Statement.

This USPSTF recommendation was first published by Agency for Healthcare Research and Quality, Rockville, MD. January 2008.
To read the recommendation, go to: http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm.

Clinical Considerations

• While the rate of illicit drug use in the U.S. is highest between the ages of 18 to 20 years, more than 10% of adolescents aged 12 to 17 are known to use illicit drugs. The percentage of adults who regularly use illicit drugs decreases steadily with age. About 5% of pregnant women report using illicit drugs within the past month.
• Marijuana is the most commonly used illicit drug in the United State, with about 6% of the population age 12 and older admitting to use within the past month. While cocaine is the second most commonly used illicit drug, it is used by less than 1% of the population. Only a small minority of Americans use hallucinogens, inhalants, heroin, or illicitly manufactured methamphetamine, although the potential for abuse of or dependence on these substances is high. Illicit (non-medical) use of prescription-type drugs, categorized as pain relievers, tranquilizers, stimulants, and sedatives, is a growing health problem in the U.S.
• While clinicians should be alert to the signs and symptoms of illicit drug use in patients, the added benefits of screening asymptomatic patients in primary care practice remains unclear. Toxicologic tests of blood or urine can provide objective evidence of drug use, but such tests do not distinguish between occasional users and those who are impaired by drug use. A few brief, standardized questionnaires have been shown to be valid and reliable in screening adolescent and adult patients for drug use/misuse. However, the clinical utility of these questionnaires is uncertain. The reported positive predictive values are variable and at best 83% when the questionnaires are applied in a general medical clinic. Moreover, the feasibility of routinely incorporating the questionnaires into busy primary care practices has yet to be assessed. The validity, reliability, and clinical utility of standardized questionnaires in screening for illicit drug use during pregnancy have not been adequately evaluated.
• Although drug-specific pharmacotherapy (e.g., buprenorphine for opiate abuse) and/or behavioral interventions (e.g., brief motivational counseling for cannabis misuse) have been proven effective in reducing illicit drug use in the short term, the longer-term effects of treatment on morbidity and mortality have been inadequately evaluated. Moreover, these treatments have been studies almost exclusively in individuals who have already developed medical, social, or legal problems due to drug use, and their effectiveness in individuals identified through screening remains unclear. In all but one trial, treatment was delivered outside the primary care setting, often in specialized treatment facilities. More evidence is needed on the effectiveness of office-based treatments for illicit drug use/dependence.
  
• While interventions to prevent or reduce illicit drug use have been proposed for use in schools and sites of employment, evidence assessing preventive measures delivered in settings other than primary care practice was outside the scope of the USPSTF review. However, the Centers for Disease Control and Prevention’s (CDC) Task Force on Community Preventive Services has announced plans to assess the effectiveness of selected population-based interventions for preventing or reducing abuse of drugs (other than tobacco and alcohol) and to make recommendations based on these findings.

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Screening for Suicide Risk

Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population. Grade: I Statement.

This USPSTF recommendation was first published in:  Ann Intern Med 2004;140:820-1.
To read the recommendation, go to: http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm.

Clinical Considerations

• The strongest risk factors for attempted suicide include mood disorders or other mental disorders, comorbid substance abuse disorders, history of deliberate self-harm (DSH), and a history of suicide attempts. DSH refers to intentionally initiated acts of self-harm with a non-fatal outcome (including self-poisoning and self-injury). Suicide risk is assessed along a continuum ranging from suicidal ideation alone (relatively less severe) to suicidal ideation with a plan (more severe). Suicidal ideation with a specific plan of action is associated with a significant risk for attempted suicide.
• Screening instruments are commonly used in specialty clinics and mental health settings. The test characteristics of most commonly-used screening instruments (Scale for Suicide Ideation [SSI], Scale for Suicide Ideation-Worst [SSI-W], and the Suicidal Ideation Questionnaire [SIQ)]) have not been validated to assess suicide risk in primary care settings. There has been limited testing of the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) screening instrument in a primary care setting.

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Counseling to Prevent Tobacco Use and Tobacco-Caused Disease

Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. Grade: A Recommendation. The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke. Grade: A Recommendation. The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children or adolescents. Grade: I Statement.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. November 2003.
To read the recommendation, go to:  http://www.ahrq.gov/clinic/uspstf/uspstbac.htm..

Clinical Considerations

• Brief tobacco cessation counseling interventions, including screening, brief counseling (3 minutes or less), and/or pharmacotherapy, have proven to increase tobacco abstinence rates, although there is a dose-response relationship between quit rates and the intensity of counseling. Effective interventions may be delivered by a variety of primary care clinicians.
• The 5-A behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions:
  1. Ask about tobacco use.
  2. Advise to quit through clear personalized messages.
  3. Assess willingness to quit.
  4. Assist to quit
  5. Arrange followup and support.
  Helpful aspects of counseling include providing problem-solving guidance for smokers to develop a plan to quit and to overcome common barriers to quitting and providing social support within and outside of treatment. Common practices that complement this framework include motivational interviewing, the 5-R's used to treat tobacco use (relevance, risks, rewards, roadblocks, repetition), assessing readiness to change, and more intensive counseling and/or referrals for quitters needing extra help.^43-45 Telephone "quit lines" have also been found to be an effective adjunct to counseling or medical therapy.⁴⁶
• Clinics that implement screening systems designed to regularly identify and document a patient's tobacco use status increased their rates of clinician intervention, although there is limited evidence for the impact of screening systems on tobacco cessation rates.⁴⁷
• FDA-approved pharmacotherapy that has been identified as safe and effective for treating tobacco dependence includes several forms of nicotine replacement therapy (i.e., nicotine gum, nicotine transdermal patches, nicotine inhaler, and nicotine nasal spray) and sustained-release bupropion. Other medications, including clonidine and nortriptyline, have been found to be efficacious and may be considered.
• Augmented pregnancy-tailored counseling (e.g., 5-15 minutes) and self-help materials are recommended for pregnant smokers, as brief interventions are less effective in this population. There is limited evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy. Tobacco cessation at any point during pregnancy can yield important health benefits for the mother and the baby, but there are limited data about the optimal timing or frequency of counseling interventions during pregnancy.
• There is little evidence addressing the effectiveness of screening and counseling children or adolescents to prevent the initiation of tobacco use and to promote its cessation in a primary care setting, but clinicians may use their discretion in conducting tobacco-related discussions with this population, since the majority of adult smokers begin tobacco use as children or adolescents.

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