Section 2. Implementing Recommendations in Academic Curricula

Implementing U.S. Preventive Services Task Force (USPSTF) Recommendati

Section 2. Implementing Recommendations in Academic Curricula

Tools for Implementation

The work of the USPSTF has been translated into several free, easy to use tools that are accessible to all health care professionals, students, and consumers. The major tools are:

1. The Electronic Preventive Services Selector (ePSS)
2. Pocket Guide to Clinical Preventive Services (updated annually)
3. These tools are available on the third tool, the USPSTF Web site at http://www.uspreventiveservicestaskforce.org/.

ePSS

The Electronic Preventive Services Selector (ePSS) is an application designed to help primary care clinicians identify the screening, counseling, and preventive medication services that are appropriate for their patients. The ePSS is available both as a Web application and a mobile application.

The Web application is a user friendly interface that is available in a print friendly format and is compatible with major browsers. The mobile application has the full functionality of the USPSTF Web application and provides for full mobility without the need for wireless or internet connectivity. The program is compatible with iPhone/iPod touch, BlackBerry, Palm OS, and Windows Mobile devices. Users can also subscribe to receive email notifications of available updates and user friendly ePSS data updates. ePSS information is based on the current recommendations of the U.S. Preventive Services Task Force and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors. Instructions on how to install the AHRQ ePSS application for BlackBerry is available at http://epss.ahrq.gov/PDA/index.jsp.

Print version of the Guide to Clinical Preventive Services

Updated annually, the Guide to Clinical Preventive Services is a spiral bound book that covers all USPSTF recommendations. Recommendations are organized for quick reference and easy searching, including an A-Z Topic Index. One section matches recommended preventive services to patients—men, women, pregnant women, and children. Single print copies of the most current version of the Guide are available free from AHRQ at: 1-800-358-9295 or AHRQPubs@ahrq.hhs.gov or can be ordered online at http://www.ahrq.gov/ppip/pporder.htm.

USPSTF Web site

The USPSTF recommendations are available on their Web site at http://www.uspreventiveservicestaskforce.org/. In addition to the recommendations, the site provides a description of the USPSTF composition, methodology, and tools for primary care practice. The site also provides an opportunity for the public to comment on draft USPSTF recommendations as well as a form for suggesting new topics to be reviewed by the USPSTF.

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Framework for Implementation

Health professions programs have several avenues for teaching preventive services. The common avenues identified include:

• Classroom/didactic.
• Pre-clinical.
• Clinical/preceptorship.
• Continuing medical education (CME).

Classroom/didactic

Prevention education can be easily incorporated in the didactic portion of health professions education. This is usually in the form of case studies for students to review, student assignments, and questions included in tests. The duration and intensity of prevention education varies for each program based on the resources available and aims of the course.

Pre-clinical

Opportunities exist to incorporate prevention education in the pre-clinical portion of health professions education. The pre-clinical period usually focuses on basic and clinical science foundational courses, and may also include courses to educate students about patient care, professionalism, and other key competencies required of health professionals.

Clinical/Preceptorship

Health Professions students observe and interact with patients in preceptors' offices during their clinical years of education. Preceptors could set an example for students through their use of USPSTF recommendations in patient care.

Continuing Education (CME and CE)

Some health professions program may develop and deliver continuing medical education courses to health professionals in their institutions and community. These courses present an opportunity to reinforce preventive services.

The case examples provided below can be used in of the learning environments described above with slight modifications. To aid educators in selecting the appropriate case study for use, the chart below maps teaching environment to specific case studies. Additionally, the appendix has examples of additional learning tools used by educators.

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Case Example 1 - ePSS

Curricular Innovations at the University of California, San Francisco (UCSF) School of Medicine.

Background

At the University of California, San Francisco (UCSF) School of Medicine, required coursework in epidemiology and evidence-based medicine (E/EBM) begins in the first year and continues throughout the third year. Material in the first 2 years is presented in large-group format with small group sessions of 10-12 students per group. These small group sessions are focused on study design and critical appraisal skills. In the third year, the E/EBM curriculum continues during a course entitled "Intersessions." Students leave the wards 3 times during the third year and go back to the classroom to focus on cross-cutting themes: ethics, health policy, advances in medical sciences and clinical decision making (CDM). The CDM course is an extension of the E/EBM curriculum and is considered "applied E/EBM."

The link between clinical research and clinical decision making is explicit in the CDM course. A 90-minute panel session entitled: "The critical link: evidence at the point of practice change" capstones the week.The overarching goal of the panel is to demonstrate the value of evidence-based medicine to a variety of stakeholders in clinical decision making including patients, clinicians, prepaid health plans, and society at large, and to stress its importance in real-world practice. The course strives to make the connection between conceptualizing evidence-based medicine as a scientific discipline to implementing it in clinical practice with the overarching goal of improving health outcomes.

To achieve this goal, small group materials have been developed that provide explicit tools for direct clinical decision making on the wards and in the clinic. These tools include materials produced by AHRQ.

Curricular materials

Large group sessions: As part of a lecture devoted to applying the principles of evidence-based medicine to patients at the point of care, students are introduced to the ePSS as a resource for efficient, tailored information for preventive care.

Small group sessions: In the small group session linked to the large group session above, students are asked to answer questions prior to the small group.

The following is an example of a small group session entitled "Finding and Applying Evidence-based Guidelines." This module takes about 30 minutes to complete.

Students are asked to use the Electronic Preventive Services Selector (ePSS) to answer the following questions. The answers are provided in blue text below.

The ePSS software cross-references the patient characteristics entered with the applicable USPSTF recommendations and generates a report specifically tailored for that patient. After the requested patient information is entered, the following Grade A and B recommendations are shown:

For this 45-year-old sexually active man who takes aspirin and has had prior normal testing for HIV, lipid disorders and syphilis and an otherwise average-risk profile, the USPSTF Grade A and B recommendations are fairly few:

For this 45-year-old sexually active man who takes aspirin and has had prior normal testing for HIV, lipid disorders, and syphilis and an otherwise average-risk profile, the 2011 USPSTF Grade A and B recommendations are fairly few.

The goal of this exercise is to illustrate where to find this information, not to discuss the rationale behind each recommendation. Students can read the full reports on-line. Instructors are therefore urged to not to get bogged down in the details of each recommendation.

From the ePSS tool search, the USPSTF gives diabetes screening a "B" recommendation among men with hyperlipidemia and/or hypertension; this patient has neither. The USPSTF gives diabetes screening an "I" statement for all other average-risk adults, meaning that evidence is insufficient to make a recommendation for or against routine testing.

Here is what you'll see (in part) if you click the link "Details" and then the tabs:

Specific recommendations: The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.

Clinical considerations: Patient Population under Consideration: This recommendation concerns adults without symptoms of diabetes or evidence of possible diabetes complications. Symptoms of diabetes include polyuria, polydipsia, and polyphagia. Possible diabetes complications include nonhealing ulcers or infections and established vascular disease (for example, coronary artery disease, stroke, and peripheral artery disease). Persons with these symptoms or conditions should be tested for diabetes.

Suggestions for practice regarding the "I" statement: In persons with blood pressure of 135/80 mm Hg or lower, screening may be considered on an individual basis if knowledge of diabetes status would help inform decisions about coronary heart disease (CHD) prevention strategies, including assessment of CHD risk and subsequent consideration of lipid-lowering agents or aspirin. For example, consider a patient for whom lipid-lowering treatment would be recommended if his or her 10-year CHD risk was 20% or greater (found in Risk Assessment section directly below). If the patient's calculated risk was 17% without diabetes and greater than 20% with diabetes, then screening for diabetes would be useful in determining lipid treatment. However, if the calculated risk was 10% without diabetes and 15% with diabetes, then the screening test result would have no effect on the decision whether to use lipid-lowering treatment.

Risk assessment: Blood pressure is an important predictor of complications of cardiovascular disease (CVD) (including CHD and stroke) in persons with type 2 diabetes mellitus and should be measured as the first step in applying this recommendation. The examination of global CHD and stroke risk allows the clinician to determine how aggressive treatment for CVD risk factors needs to be. In making this assessment, clinicians should use any of several validated CHD risk assessment calculators, such as the calculator based on Framingham Heart Study data (available at http://www.mcw.edu/calculators/CoronaryHeartDiseaseRisk.htm).

Screening tests: Three tests have been used to screen for diabetes: fasting plasma glucose, 2-hour postload plasma glucose, and hemoglobin A_1c. Each has advantages and disadvantages. The American Diabetes Association has recommended the fasting plasma glucose test for screening because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive than other screening tests. The fasting plasma glucose test has more reproducible results than does the 2-hour postload plasma glucose test, has less intraindividual variation, and has similar predictive value for development of microvascular complications of diabetes. The American Diabetes Association defines diabetes as a fasting plasma glucose level of 126 mg/dL or greater and recommends confirmation with a repeated screening test on a separate day, especially for people with borderline results.

Treatment of Persons with Sustained Blood Pressure of 135/80 mm Hg or Greater: Blood pressure targets should be lower for persons who have type 2 diabetes mellitus than for those who do not. Lower blood pressure targets for persons with diabetes and high blood pressure reduce CVD events compared with higher targets. Attention to other risk factors for CVD, such as physical inactivity, lipid levels, diet, and obesity, is also important, both to decrease risk for CHD and to improve glucose control.

Screening intervals: The optimal screening interval is not known. The American Diabetes Association, on the basis of expert opinion, recommends a 3-year interval.

Other approaches to prevention: There is no evidence of benefit in health outcomes from screening for impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). However, intensive programs of lifestyle modification (diet, exercise, and behavior) do reduce the incidence of diabetes. Regardless of whether the clinician and patient decide to screen for diabetes, people should eat a healthful diet, be active, and maintain a healthy weight - these behaviors have other benefits in addition to preventing or forestalling type 2 diabetes. The USPSTF recommends intensive interventions for obese persons who desire to lose weight. Population-based approaches to increasing physical activity and reducing obesity, as recommended by the USPSTF on Community Preventive Services, should be supported.

Useful resources: Evidence and USPSTF recommendations on blood pressure, diet, physical activity, and obesity are available at http://www.preventiveservices.ahrq.gov. The reviews and recommendations for the Task Force on Community Preventive Services may be found at http://www.thecommunityguide.org.

Other considerations: Research Needs: The types of studies that would help fill gaps in the evidence include a randomized (or nonrandomized), controlled trial of screening for type 2 diabetes mellitus; extended follow-up of the UKPDS (United Kingdom Prospective Diabetes Study) and other cohort studies; studies of glycemic control, with CHD outcomes, in screening-detected populations; studies of optimal lipid and blood pressure targets for people with screening-detected diabetes; and studies examining the impact of a diagnosis of prediabetes on the effectiveness of lifestyle interventions.

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Case Example 2 - AHRQ Web Site

Finding and Applying Evidence-based Guidelines Using the AHRQ Web site.

Background

The following case was devised by George Sawaya, MD for the purposes of this implementation guide. The case guides instructors on how to navigate the AHRQ web site to arrive at the USPSTF recommendations. The USPSTF recommendations can be accessed directly from the Web site at http://www.uspreventiveservicestaskforce.org/recommendations.htm.

Recommendations are available through an A-Z Topic Index on the Web site and through clinical categories/conditions organized by adults, children and adolescents. The Web site also features a list of topics that are currently under review by the USPSTF. The following example can be completed in a small group session and takes about 40 minutes to complete.

Students are asked to use the AHRQ Web site to answer the following questions. The answers are provided in blue text below.

The USPSTF recommendations for preventive services can be accessed from the AHRQ Web site at http://www.uspreventiveservicestaskforce.org/index.html. Recommendations are available through an A-Z Topic Index on the web site and through clinical categories/conditions organized by adults, children and adolescents. In the Topic Index, the breast cancer screening recommendation can be accessed at http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. The recommendation reads: "The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation."

Students will have been introduced to the USPSTF ratings in class. They should know that the "C" recommendation means that the USPSTF "recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient."

The USPSTF further states that services with a "C" be offered or provided only if other considerations support the offering or providing the service in an individual patient. In other words, such services should not automatically be applied to individuals without first considering other factors.

In terms of certainty and magnitude of net benefit, a C recommendation means that there is "at least moderate certainty that the net benefit is small."

The USPSTF recommendation statement can be accessed at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Here, the USPSTF clarifies the benefits, harms and balance between the two.

For benefits pertinent to this 40-year-old patient, the USPSTF states: "There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for women aged 40 to 49 years."

The USPSTF realizes that harms can take many forms. For general harms resulting from screening for breast cancer, the USPSTF lists the following:
psychological harms, unnecessary imaging tests and biopsies in women without cancer, and inconvenience due to false-positive screening results; treatment of cancer that would not become clinically apparent during a woman's lifetime (overdiagnosis), unnecessary earlier treatment of breast cancer that would have become clinically apparent but would not have shortened a woman's life; radiation exposure (a minor concern)

For harms pertinent to this 40-year-old patient, the USPSTF states:
"Adequate evidence suggests that the overall harms associated with mammography are moderate for every age group considered, although the main components of the harms shift over time. Although false-positive test results, overdiagnosis, and unnecessary earlier treatment are problems for all age groups, false-positive results are more common for women aged 40 to 49 years, whereas overdiagnosis is a greater concern for women in the older age groups."

In the Discussion section of the Recommendation statement (http://www.uspreventiveservicestaskforce.org/uspstf09/breastcancer/brcanrs.htm), the USPSTF details the estimation of magnitude of net benefit:

"In 2002, the USPSTF concluded that there was fair evidence that mammography screening every 12 to 33 months could significantly reduce breast cancer mortality. The evidence was strongest for women aged 50 to 69 years, with weaker evidence supporting mammography screening for women aged 40 to 49 years. Since that recommendation, 1 new trial and updated data from an older study have been published that specifically address screening in women in the younger age group. These findings were combined in an updated meta-analysis, which resulted in an RR for breast cancer death of 0.85 (CI, 0.75 to 0.96; 8 trials) and a number needed to invite for screening of 1904 (CI, 929 to 6378) to prevent 1 breast cancer death in women aged 39 to 49 years."

They conclude: "For women aged 40 to 49 years, the USPSTF had moderate certainty that the net benefits were small."

Shared informed decision making is the process by which patients and caregivers come to an agreement about a healthcare decision. It is especially useful when there is no clear "best" treatment option. The USPSTF "C" recommendations can be thought of as fitting this bill. The information used and methods employed to achieve shared informed decision making vary widely, ranging from passive to detailed and active.

Understanding the likelihood of various options in quantitative terms may be helpful for some patients. The USPSTF provides a table with outcomes per screening round in a theoretic cohort of women. These results indicate that in a single screening round, women aged 40-49 have about a 9.8% chance of a false-positive mammogram, a 8.4% chance of additional testing and a 0.9% chance of a having a biopsy. Her chance of being diagnosed with breast cancer is 0.18%. She should be aware that even though her breast cancer may be detected by mammography, this does not mean that she will not die of breast cancer.

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Case Example 3 - Annual Guide - The Guide to Clinical Preventive Services

Incorporating USPSTF Clinical Guidelines in a Physician Assistant Curriculum.

Background

In the "Preventive and Behavioral Medicine" course for physician assistant students at Wichita State University, Timothy F. Quigley, MPH, PA-C, uses the U.S. Preventive Services Task Force recommendations as the foundation of his curriculum. According to Quigley, the course in preventive medicine is offered as one of the first courses in the physician assistant program. The goals are to introduce and emphasize the importance of preventive and evidence-based medicine in the practice of medicine. For nearly 13 years, Quigley has used USPSTF materials—initially providing hard copies of the recommendations as part of his classroom resources. As the formats for the distribution of the recommendations have expanded, student resources have multiplied, too. In addition to being required to obtain a copy of the Guide to Clinical Preventive Services from AHRQ, students also use the online resources regularly for drilling deeper into the Evidence Review, etc.

The course is heavily dependent on the online course platform "Blackboard" where all readings, handouts, articles and web links are posted. For each section of the Preventive Medicine course (e.g. Cancer or Infectious Disease), there are hyperlinks taking the student directly to the USPSTF Web page on that topic. The students are basically expected to know all the A (strongly recommended) and B (recommended) services, and to be able to discuss the recommendations and rationale with patients and other clinicians. Finally, when the students enter their clinical rotations they are required to carry PDAs to log their clinical encounters and to access drug and prescribing information.

Students are asked to use The Guide to Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force to answer the following questions.

The Guide, which is designed to be a point-of-care clinical tool, includes a readily accessible table of recommended preventive services for adults, children and pregnant women. Section 2 offers abridged Recommendation Statements and abridged Clinical Considerations for each preventive service. (Users are encouraged to visit the more comprehensive web site, http://www.uspreventiveservicestaskforce.org/index.html to read the complete recommendation statements, including those that were published online after the latest Guide printing.)

By consulting the section, Preventive Services Recommended by the USPSTF, the student can immediately find the A and B recommendations for a 66 year-old, post-menopausal, female smoker with hypertension, no sexual infection risk factors and recent normal Pap smears (shown under the column for ‘Women’).

By consulting the Cancer section in the Guide, (Lung Cancer Screening), one sees that the USPSTF concluded that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with CT or chest x-ray. (Grade: I Statement). The rationale for issuing the Grade I Statement is found under Clinical Considerations section.

By consulting the Cancer section of Guide, one sees that that the USPSTF recommendation for cervical cancer is under review. Users are advised to visit the USPSTF Web site for the updated recommendation. The current recommendations noted on page 25 of the Guide involves a Grade D Recommendation against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer.

Additional explanation is provided under the Clinical Considerations section:

Discontinuation of cervical cancer screening in older women is appropriate, provided women have had adequate recent screening with normal Pap results. The optimal age to discontinue screening is not clear, but risk of cervical cancer and yield of screening decline steadily through middle age. The USPSTF found evidence that yield of screening was low in previously screened women after age 65. New American Cancer Society (ACS) recommendations suggest stopping cervical cancer screening at age 70. Screening is recommended in older women who have not been previously screened, when information about previous screening is unavailable, or when screening is unlikely to have occurred in the past (e.g., among women from countries without screening programs). Evidence is limited to define "adequate recent screening." The ACS guidelines recommend that older women who have had three or more documented, consecutive, technically satisfactory normal/negative cervical cytology tests, and who have had no abnormal/positive cytology tests within the last 10 years, can safely stop screening.

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