Talk More, Test Less, Panel Urges Health Providers

A task force of preventive health specialists recently recom its,significantly change the use of some screening tests, and ensurethat several newer immunizations are routinely provided.

The US Preventive Services Task Force, an independent panel firstconvened in 1984 as an initiative of the US Public Health Service,issued the first revision of its 1989 guide to disease preventionand health promotion, based on a review of scientific evidence.

Many of the recommended changes in the 1995 "Guide to ClinicalPreventive Services, 2nd Edition" reflect new evidence aboutimportant health benefits of selected preventive services, accordingto the panel. Other changes reflect a more critical look at thebalance of harms and benefits of screening tests now in wide use.The report also reaffirms many of the disease- and injury-preventionpractices recommended in 1989.

In accepting the report from the task force, Philip R. Lee, MD,assistant secretary for health, noted that "effective diseaseand injury prevention is our most efficient tool for improvingour health status as individuals and as a nation. This report,like its predecessor, moves us further toward prevention thatworks."

Targeting the Periodic Health Exam

The 10-member task force rejected the traditional emphasis ona standardized annual physical examination as an effective toolfor improving the health of patients. Instead, they emphasizedthat the content and frequency of the periodic health examinationneed to be tailored to the age, health risks, and preferencesof each patient.

The panel recognized the proven benefits of specific measures,such as periodic screening for high blood pressure and cervicalcancer, scheduled vaccinations, and counseling about tobacco,alcohol, and other lifestyle issues. In contrast, the task forcefound little evidence of important benefits from other tests oftenincluded in routine check-ups, such as blood tests for diabetes,thyroid diseases, or anemia; chest x-rays; ECGs; and urine tests.

"Our review affirms the effectiveness of a variety of preventiveinterventions, many of which are underutilized in routine practice.At the same time, other widely used preventive practices, manyof which are costly and some of which are even dangerous, showlittle or no evidence that they improve health," said HaroldC. Sox, Jr, MD, task force chair. "We based our recommendationson the scientific evidence. All too often, the evidence was tooweak for us to make a strong recommendation. We need to strengthenthe evidence on which our prevention practices rest," addedDr. Sox, who is chair of medicine at Dartmouth-Hitchcock MedicalCenter.

Although none of the recommendations depended on cost, the taskforce noted the considerable cost of the widespread use of manyunproven tests and procedures, such as routine ECGs in healthyadults and ultrasound scans in low-risk pregnancies.

The task force included specialists in family medicine, internalmedicine, obstetrics and gynecology, pediatrics, and preventivemedicine. Over 30 outside experts in medicine, nursing, publichealth, epidemiology, and health promotion and education alsocontributed to the project.

The panel assessed more than 6,000 studies of over 200 differentinterventions for more than 70 diseases and conditions. Theseincluded 53 screening tests (for cardiovascular disease, cancer,metabolic and nutritional diseases, infectious diseases, visionand hearing disorders, prenatal disorders, congenital disorders,musculoskeletal disorders, mental disorders and substance abuse);11 counseling topics ranging from promoting seat belt use to preventingtobacco use; immunization against 12 common childhood and adultdiseases; and the use of aspirin and postmenopausal hormones toprevent disease.

The task force has been a pioneer in rigorously evaluating scientificevidence to decide the merits of prevention measures. Since thepublication of the 1989 report, the evidence-based method hasbecome the standard for developing guidelines for medical andnursing practice. Based on this method, the task force recommendsonly those preventive services with demonstrated effectivenessin preventing disease, disability, or death.

Broad Conclusions About Effective Preventive Care

The report draws several broad conclusions about effective preventivecare:

• Counseling patients about personal health practices (smoking,diet, physical activity, drinking, injury prevention, and sexualpractices) remains one of the most underused, but important, partsof the health visit.
• Preventive services offered by the clinician should be tailoredto the specific behaviors and risk factors of individual patients,not offered as a standard "routine check-up" given toall patients.
• Patients should share in decisions about preventive services.Their personal preferences are important in determining an approachto prevention that is optimal for them as individuals. This isespecially true when the evidence of benefit is weak.
• Doctors and nurses should try to deliver prevention messagesand services during every encounter with their patients, especiallyfor high-risk patients who are often the least likely to see cliniciansfor routine check-ups.

Value of Specific Preventive Strategies Endorsed or Rejected

The new or revised recommendations support:

• Flexible sigmoidoscopy and/or annual fecal occult blood testingto screen for colorectal cancer
• Targeting routine screening for high cholesterol and otherlipid disorders to men 35 to 65 years old, women ages 45 to 65,and others at increased risk for heart disease
• Daily multivitamins with folic acid for all women who canbecome pregnant (to prevent neural tube defects)
• Routine vaccination of all newborns, children, adolescents,and young adults against hepatitis B
• Routine vaccination of children against chickenpox
• Counseling parents of young children on measures to reducethe risk of household and recreational injuries
• Discussion of the use of estrogen therapy with all postmenopausalwomen

On the other hand, the panel came out against:

• Routine screening for prostate cancer with prostate-specificantigen (PSA) or digital rectal examination
• Routine urine tests for early detection of bladder canceror asymptomatic urinary tract infection

To order a printed copy of the "Guide to Clinical PreventiveServices, 2nd Edition, " contact the superintendent of Documents,US Govenment Printing Office, at 202-512-1800. The stock numberof the publication is 017-001-00525-8 and the single copy priceis $35 (shipping included).

Internet access to the guide will be available in early 1966via the National Library of Medicine' HSTAT (Health Services/TechnologyAssessment Text) database at http:// text.nim.nih.gov/ and theOffice of Disease Prevention and Health Promotion at http://odphp.oash.dhhs.gov/.