Practice Alert

The latest recommendations from the USPSTF

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Four “B” recommendations now qualify for first-dollar insurance coverage as mandated by the Affordable Care Act and 5 “D” recommendations advise against some commonly used interventions—including PSA screening.


 

References

Since the last Practice Alert update on the US Preventive Services Task Force (USPSTF) recommendations,1 the Task Force released 16 final recommendations, through January of this year (TABLE).2 However, none of these were level A recommendations and only 4 were level B. This is significant in that USPSTF level A and B recommendations must now be covered by health insurance plans without patient cost sharing as a result of a clause in the Affordable Care Act. There were 5 D recommendations (recommend against), and some of the tests that fell into this category are in common use. I discuss the B and D recommendations below.

TABLE
Recent recommendations from the USPSTF2

B recommendations
The USPSTF recommends:
  • encouraging community-dwelling adults ≥65 years who are at increased risk for falls to take vitamin D supplements and to exercise (or undergo physical therapy) to prevent falls.
  • screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) ≥30 kg/m2 to intensive, multicomponent behavioral interventions.
  • counseling children, adolescents, and young adults ages 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce their risk of skin cancer.
  • screening women of childbearing age for intimate partner violence, such as domestic violence, and providing or referring women who screen positive to intervention services.
C recommendations
The USPSTF recommends against automatically:
  • performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults ≥65 years because the likelihood of benefit is small. 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 the circumstances of prior falls, comorbid medical conditions, and patient values.
  • initiating counseling on a healthful diet and physical activity with all adults in the general population. Although the correlation among healthful diet, physical activity, and the incidence of cardiovascular disease is strong, existing evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting is small. Clinicians may choose to selectively counsel patients rather than incorporate counseling into the care of all of their adult patients.
D recommendations
The USPSTF recommends against:
  • screening with resting or exercise electrocardiography (EKG) for the prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for such events.
  • using combined estrogen and progestin to prevent chronic conditions in postmenopausal women.
  • using estrogen to prevent chronic conditions in postmenopausal women who have had a hysterectomy.
  • screening for ovarian cancer.
  • screening for prostate cancer with a prostate-specific antigen (PSA) test.
I statements
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of:
  • screening for hearing loss in asymptomatic adults ages ≥50 years.
  • screening with resting or exercise EKG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events.
  • routine screening for chronic kidney disease in asymptomatic adults.
  • counseling adults >24 years about minimizing risks to prevent skin cancer.
  • screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect.
For more on the USPSTF’s grade definitions, see http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm.

B recommendations

Encourage vitamin D supplementation and regular exercise to prevent falls in elderly
Falls in the elderly are a significant cause of morbidity and mortality. The Task Force found that between 30% and 40% of community-dwelling adults ≥65 years fall each year, and 5% to 10% of those who fall will sustain a fracture, head injury, or laceration.3 Those at highest risk have a history of falls, report mobility problems, have chronic diseases, use psychotropic medications, or have difficulty on a “get up and go” test, which involves rising from a sitting position in an arm chair, walking 10 feet, turning, walking back, and sitting down. If this activity takes more than 10 seconds, the risk of a fall is increased.3

Two interventions were found to be effective in preventing falls: vitamin D supplementation and regular exercise or physical therapy. Vitamin D enhances muscular strength and balance, and supplementation of 800 IU daily for 12 months can decrease the risk of a fall by 17%, with a number needed to treat (NNT) of 10 to prevent one fall.3 Exercise or physical therapy that focuses on gait and balance, strength or resistance training, or general fitness can reduce the risk of falls with an NNT of 16. Individuals who benefit the most are those at higher risk.3

As for multifactorial risk assessment and comprehensive management of risks to prevent falls, a pooled analysis of studies showed that these interventions do little to reduce falls and do not warrant routine use. The Task Force evaluated other interventions—vision correction, medication discontinuation, protein supplementation, education or counseling, and home hazard modification—but could not find sufficient evidence to recommend for or against them.

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