Advertisement

Broadening the Evidence Base for Evidence-Based Guidelines

A Research Agenda Based on the Work of the U.S. Preventive Services Task Force
  • David Atkins MD, MPH
    Correspondence
    Dr. Atkins, U.S. Preventive Services Task Force, Agency for Health Care Policy and Research, 6000 Executive Blvd., Suite 310, Rockville, Maryland 20852.
    Footnotes
    Affiliations
    U.S. Preventive Services Task Force, Agency for Health Care Policy and Research, Rockville, Maryland, 20852, USA.
    Search for articles by this author
  • Carolyn G. DiGuiseppi MD, MPH
    Footnotes
    Affiliations
    U.S. Preventive Services Task Force, Agency for Health Care Policy and Research, Rockville, Maryland, 20852, USA.
    Search for articles by this author
  • Author Footnotes
    1 The views contained in this paper are solely those of the authors and do not reflect official policies of the Agency for Health Care Policy and Research or the U.S. Public Health Service, nor do they necessarily reflect the views of the U.S. Preventive Services Task Force.
    3 The views contained in this paper are solely those of the authors and do not reflect official policies of the Agency for Health Care Policy and Research or the U.S. Public Health Service, nor do they necessarily reflect the views of the U.S. Preventive Services Task Force.
    2 Dr. DiGuiseppi’s current affiliation is: Institute of Child Health, University College London, London, UK.

      Abstract

      Evidence-based evaluations of clinical preventive services help define priorities for research in prevention as part of primary health care. In this article, we draw on our experiences with the U.S. Preventive Services Task Force (USPSTF) to outline some major areas where research is needed to define the appropriate use of specific screening tests, counseling interventions, immunizations, and chemoprophylaxis. Areas of particular importance included research to: (1) Identify effective and practical primary care interventions for modifying personal health practices of patients, especially around issues such as diet, exercise, alcohol and drug use, and risky sexual behavior; (2) Clarify the optimal periodicity for certain screening tests and counseling interventions; (3) Identify practical ways to allow patients to share decision-making about preventive care, especially for services of possible but uncertain benefit; (4) Examine the most sensitive and efficient ways to identify high-risk groups who may need different services than the average population; and (5) Expand the use of decision-analysis and cost-effectiveness analysis to help identify optimal use of clinical preventive services. Given the difficulty of large, prospective trials, we discuss the use of alternative research designs to fill in critical gaps in the evidence for the effectiveness of specific services. Finally, we note several issues of increasing importance that may need to be addressed by future work of the USPSTF: what are the most reliable and effective ways to (1) measure and (2) improve the delivery and quality of preventive care provided in the primary care setting.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Eddy DM
        A manual for assessing health practices and designing practice policies. American College of Physicians, Philadelphia1992
      1. U.S. Preventive Services Task Force. Guide to clinical preventive services, 2nd ed. Baltimore: Williams and Wilkins; 1996.

        • Canadian Task Force on the Periodic Health Examination
        The Canadian guide to clinical preventive health care. Canada Communication Group, Ottawa1994
        • Eddy DM
        Common screening tests. American College of Physicians, Philadelphia1991
        • U.S. Preventive Services Task Force
        Guide to clinical preventive services. Williams & Wilkins, Baltimore, Maryland1989
        • McGinnis JM
        • Foege WH
        Actual causes of death in the United States.
        JAMA. 1993; 270: 2207-2212
        • Glanz K
        • Lewis FM
        • Rimer BK
        Health behavior and health education. Jossey-Bass, San Francisco1990
        • Green LW
        • Kreuter MW
        Health promotion planning. 2nd ed. Mayfield Publishing Co, Mountain View, California1991
      2. Institute of Medicine. The best intentions: unintended pregnancy and the well-being of children and families. Brown SS, Eisenberg L, eds. Washington, DC: National Academy Press; 1995.

      3. Institute of Medicine. AIDS and behavior: an integrated approach. Auerbach JD, Wypijewska C, Brodie HKH, eds. Washington, DC: National Academy Press; 1994.

        • Cohen DA
        • MacKinnon DP
        • Dent C
        • et al.
        Group counseling at STD clinics to promote use of condoms.
        Public Health Rep. 1992; 107: 727-731
        • Rickert VI
        • Gottlieb AA
        • Jay MS
        Is AIDS education related to condom acquisition?.
        Clin Pediatr (Phila). 1992; 31: 205-210
        • Caggiula AW
        • Christakis G
        • Farrand M
        • et al.
        The Multiple Risk Factor Intervention Trial (MRFIT). IV. Intervention on blood lipids.
        Prev Med. 1981; 10: 443-475
      4. The Writing Group for the DISC Collaborative Research Group. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol: the Dietary Intervention Study in Children (DISC). JAMA 1995;273:1429–35.

        • Kottke TE
        • Battista RN
        • DeFriese GH
        • et al.
        Attributes of successful smoking cessation interventions in medical practice.
        JAMA. 1988; 259: 2882-2889
        • Bien TH
        • Miller WR
        • Tonigan JS
        Brief interventions for alcohol problems.
        Addiction. 1993; 88: 315-336
        • Bass J
        • Christoffel K
        • Widome M
        • et al.
        Childhood injury prevention counseling in primary care settings.
        Pediatrics. 1993; 92: 544-553
        • Ramsay LE
        • Yeo WW
        • Jackson PR
        Dietary reduction of serum cholesterol concentration.
        BMJ. 1991; 303: 953-957
        • Gibbins RL
        • Riley M
        • Brimble P
        Effectiveness of programme for reducing cardiovascular risk for men in one general practice.
        BMJ. 1993; 306: 1652-1656
        • Neil HAW
        • Roe L
        • Godlee RJP
        • et al.
        Randomised trial of lipid lowering dietary advice in general practice.
        BMJ. 1995; 310: 569-573
        • Ammerman A
        • Caggiula A
        • Elmer PJ
        • et al.
        Putting medical practice guidelines into practice.
        Am J Prev Med. 1994; 10: 209-216
        • Caggiula AW
        • Watson JE
        • Kuller LH
        • et al.
        Cholesterol-Lowering Intervention Program.
        Arch Intern Med. 1996; 156: 1205-1213
        • Schectman G
        • Wolff N
        • Byrd JC
        • et al.
        Physician extenders for cost-effective management of hypercholesterolemia.
        J Gen Intern Med. 1996; 11: 277-286
        • Higgins DL
        • Galavotti C
        • O’Reilly KR
        • et al.
        Evidence for the effects of HIV antibody counseling and testing on risk behaviors.
        JAMA. 1991; 266: 2419-2429
        • Slater M
        Health for our children. Action for Sick Children, London1993
      5. Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Washington, DC: U.S. Government Printing Office; 1994; Publication no. S/N 017-001-00491-0.

        • Kerlikowske K
        • Grady D
        • Rubin SM
        • et al.
        Efficacy of screening mammography.
        JAMA. 1995; 273: 149-154
        • Selby JV
        • Friedman GD
        • Quesenberry CP
        • et al.
        A case-control study of screening sigmoidoscopy and mortality from colorectal cancer.
        N Engl J Med. 1992; 326: 653-657
        • Pauker SG
        • Kassirer JP
        Contentious screening decisions.
        New Engl J Med. 1997; 336: 1243-1244
        • Col NF
        • Eckman MH
        • Karas RH
        • et al.
        Patient-specific decisions about hormone replacement therapy in postmenopausal women.
        JAMA. 1997; 277: 1140-1147
        • Spencer K
        • Carpenter P
        Prospective study of prenatal screening for Down’s syndrome with free β human chorionic gonadotrophin.
        BMJ. 1993; 307: 764-769
        • Haddow JE
        • Palomaki GE
        • Knight GJ
        • et al.
        Prenatal screening for Down’s syndrome with use of maternal serum markers [see comments].
        N Engl J Med. 1992; 327: 588-593
        • Abuelo D
        • Hopmann MR
        • Barsel-Bowers G
        • et al.
        Anxiety in women with low maternal serum alpha-fetoprotein screening results.
        Prenat Diagn. 1991; 11: 381-385
        • Smith DS
        • Catalona WJ
        • Herschman JD
        Longitudinal screening for prostate cancer with prostate-specific antigen.
        JAMA. 1996; 276: 1309-1315
        • Wennberg JE
        Improving the decision-making process.
        Health Aff (Millwood). 1988; 7: 99-106
        • Greenfield S
        • Kaplan SH
        • Ware Jr, JE
        Expanding patient involvement in care.
        Ann Intern Med. 1985; 102: 520-528
        • Ernster VL
        Mammography screening for women aged 40 through 49.
        Am J Public Health. 1997; 87: 1103-1106
        • Handley MR
        • Stuart ME
        The use of prostate specific antigen for prostate cancer screening.
        J Urol. 1994; 152: 1689-1692
        • Flood AB
        • Wennberg JE
        • Nease RF
        • et al.
        The importance of patient preferences in the decision to screen for prostate cancer.
        J Gen Intern Med. 1996; 11: 342-349
        • Chan E
        • Sulmasy D
        What do patients need to know about PSA screening? [abstract].
        J Gen Intern Med. 1996; 11: 114
        • Stergachis A
        • Scholes D
        • Heidrich FE
        • et al.
        Selective screening for Chlamydia trachomatis infection in a primary care population of women.
        Am J Epidemiol. 1993; 138: 143-153
        • Scholes D
        • Stergachis A
        • Heidrich FE
        • et al.
        Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection.
        N Engl J Med. 1996; 334: 1362-1366
        • Krahn MD
        • Mahoney JE
        • Eckman MH
        • et al.
        Screening for prostate cancer; a decision analytic review.
        JAMA. 1994; 272: 773-780
        • Coley CM
        • Barry MJ
        • Fleming C
        • et al.
        Early detection of prostate cancer..
        Ann Intern Med. 1997; 126: 468-479
        • Gold MR
        • Siegel JE
        • Russell LB
        • Weinstein MC
        Cost-effectiveness in health and medicine. Oxford University Press, New York1996
        • Gray JAM
        Evidence-based health care. Churchill Livingstone, London1996
        • Lieu TA
        • Cochi SL
        • Black SB
        • et al.
        Cost-effectiveness of a routine varicella vaccination program for US children.
        JAMA. 1994; 271: 375-381
        • Winawer SJ
        • Fletcher RH
        • Miller L
        • et al.
        Colorectal cancer screening.
        Gastroenterology. 1997; 112: 594-642
        • Johannesson M
        • Jonsson B
        • Kjekshus J
        • et al.
        Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group.
        N Engl J Med. 1997; 336: 332-336
      6. Centers for Disease Control and Prevention. Screening young children for lead poisoning: guidance for state and local public health officials. Atlanta, Georgia: Centers for Disease Control and Prevention; 1997.

        • Lee TT
        • Solomon NA
        • Heidenreich PA
        • et al.
        Cost-effectiveness of screening for carotid artery stenosis in asymptomatic persons.
        Ann Intern Med. 1997; 126: 337-346
        • Omenn GS
        • Goodman GE
        • Thornquist MD
        • et al.
        Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease.
        N Engl J Med. 1996; 334: 1150-1155
        • Hennekens CH
        • Buring JE
        • Manson JE
        • et al.
        Lack of effect of long-term supplementation with beta-carotene on the incidence of malignant neoplasms and cardiovascular disease.
        N Engl J Med. 1996; 334: 1145-1149
        • Woolf SH
        • DiGuiseppi CG
        • Atkins D
        • Kamerow DB
        Developing evidence-based clinical practice guidelines: lessons learned by the U.S. Preventive Services Task Force.
        Annu Rev Public Health. 1996; 17: 511-538
        • The Lipid Research Clinics Coronary Primary Prevention Project
        1. Reduction in incidence of coronary heart disease.
        JAMA. 1984; 251: 351-364
        • Frick MH
        • Elo O
        • Haapa K
        • et al.
        Helsinki Heart Study.
        N Engl J Med. 1987; 317: 1237-1245
        • Shepherd J
        • Cobbe SM
        • Ford I
        • et al.
        Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia.
        N Engl J Med. 1995; 333: 1301-1307
      7. Office on Smoking and Health, Centers for Disease Control. The health benefits of smoking cessation. Rockville, Maryland: U.S. Department of Health and Human Services; 1990; DHHS Publication No. (CDC) 90-8416.

        • Andrade SE
        • Walker AM
        • Gottlieb LK
        • et al.
        Discontinuation of antihyperlipidemic drugs.
        N Engl J Med. 1995; 332: 1125-1131
        • Litwin MS
        • Hays RD
        • Fink A
        • et al.
        Quality-of-life outcomes in men treated for localized prostate cancer.
        JAMA. 1995; 273: 129-135
        • Gann PH
        • Hennekens CH
        • Stampfer M
        A prospective evaluation of plasma prostate-specific antigen for detection of prostatic cancer.
        JAMA. 1995; 273: 289-294
        • Kleijnen J
        • Gotzsche P
        • Kunz RA
        • et al.
        So what’s so special about randomisation?.
        in: Maynard A Chalmers I Non-random reflections on health services research on the 25th anniversary of Archie Cochrane’s Effectiveness and Efficiency. BMJ Publishing Group, London1997: 93-106
        • Thompson RS
        • Rivara FP
        • Thompson DC
        A case-control study of the effectiveness of bicycle safety helmets.
        N Engl J Med. 1989; 320: 1361-1367
        • Thomas S
        • Acton C
        • Nixon J
        • et al.
        Effectiveness of bicycle helmets in preventing head injury in children.
        BMJ. 1994; 308: 173-176
      8. Chalmers TC. Implications of meta-analysis: need for a new generation of randomized control trials. In: McCormick KA, Moore SR, Siegel RA, eds. Clinical practice guideline development: methodology perspectives. Rockville, Maryland: U.S. Department of Health and Human Services; 1994; AHCPR Pub. No. 95-0009.

        • LeLorier J
        • Gregoire G
        • Benhaddad A
        • et al.
        Discrepancies between meta-analyses and subsequent large randomized, controlled trials.
        N Engl J Med. 1997; 337: 536-542
      9. Hedges LV. Combining estimates across studies: meta-analysis of research. In: McCormick KA, Moore SR, Siegel RA, eds. Clinical practice guideline development: methodology perspectives. Rockville, MD: U.S. Department of Health and Human Services; 1994; AHCPR Pub. No. 95-0009.

        • Mulrow CD
        • Cook DJ
        • Davidoff F
        Systematic reviews.
        Ann Intern Med. 1997; 126: 389-391
        • Bero L
        • Rennie D
        The Cochrane Collaboration. Preparing, maintaining, and disseminating systematic reviews of the effects of health care.
        JAMA. 1995; 274: 1935-1938
        • Antiplatelet Trialists’ Collaboration
        Collaborative overview of randomised trials of antiplatelet therapy. I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients.
        BMJ. 1994; 308: 81-106
        • Buchner DM
        • Hornbrook MC
        • Kutner NG
        • et al.
        Development of the common data base for the FICSIT trials.
        J Am Geriatr Soc. 1993; 41: 297-308
        • Ory MG
        • Schechtman KB
        • Miller JP
        • et al.
        Frailty and injuries in later life.
        J Am Geriatr Soc. 1993; 41: 283-296
        • Province MA
        • Hadley EC
        • Hornbrook MC
        • et al.
        The effects of exercise on falls in elderly patients.
        JAMA. 1995; 273: 1341-1347
        • Pocock SJ
        • Smith M
        • Baghurst P
        Environmental lead and children’s intelligence.
        Br Med J. 1994; 309: 1189-1197
        • Begg C
        • Cho M
        • Eastwood S
        • et al.
        Improving the quality of reporting of randomized controlled trials. The CONSORT statement.
        JAMA. 1996; 276: 637-639
        • Grimshaw JM
        • Russell IT
        Effect of clinical guidelines on medical practice.
        Lancet. 1993; 342: 1317-1322
      10. Implementing clinical practice guidelines.
        Effective Health Care. 1994; 8: 1-12
      11. National Committee for Quality Assurance. Health Plan Employer Data and Information Set (HEDIS 3.0). Washington, DC: NCQA; 1997.