Prevention Guidelines for PC

Prevention Guidelines for Primary Care in the Age of Affordable Care

 

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Guidance on what preventive services are appropriate and will be reimbursed by third parties has become more uniform with the passage of the Affordable Care Act. All third party payers participating in the Affordable Care Act (ACA), Medicare or Medicaid (CMS), are required to reimburse for a set of preventive services, as long as they are delivered by a network provider. However the decision on which service(s) are appropriate for an individual is still made by the provider and patient.

Medicare began to pay for both an initial and annual follow-up “Wellness” visit in 2014 for individuals enrolled in Part B. Individuals are eligible for the initial exam only within the first 12 months after signing up for Part Β, but the initial visit is not required to be covered for subsequent yearly “Wellness” visits. After 12 months, individuals may visit their provider to develop a personalized prevention plan in preparation for the yearly “Wellness” visit. Guidelines for health care providers on how to conduct and document these visits are available through the “Medicare Learning Network”.  Again there is some latitude in decision-making for services appropriate to an individual.

Although published clinical practice guidelines for preventive services are by no means uniform and in fact are often controversial, the guidelines of the Federal Department of Health and Human Services are the de facto standard for reimbursable preventive care. The Federal guidelines are based on the recommendations of the U.S. Preventive Services Task Force (USPTF) of the Agency for Healthcare Research and Quality (AHRQ). The current recommendations for primary care practices are available at the USPTF.  There are several tools available for download for primary care providers. Unfortunately none of these tools are currently adapted to integrate with an electronic medical record (EMR) system to provide automated clinical decision support.

There are several notable changes in USPTF recommendations since the publication of the CMS and ACA guidance noted above. One way to keep track of new recommendations as they occur is to use the Electronic Preventive Services Selector. The current edition of the USPTF Guide to Clinical Preventive Services was published in March 2014 and includes 28 new or updated recommendations since the 2012 edition. I will attempt to isolate summaries of changes published since March, 2014 in this article. I identified these recommendations using a search of years 2014-2015 at the USPTF Published Recommendations by date. I am including only those changes to which we are advised to respond with a change in intervention, but not topics considered with no intervention or alteration in intervention supported by the evidence review. Full reviews including clinical considerations and the evidence strength for the recommendations are accessible at the USPTF website.

Abdominal Aortic Aneurysm Screening: The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men ages 65 to 75 years who have ever smoked. The USPSTF recommends that clinicians selectively offer screening for AAA in men ages 65 to 75 years who have never smoked rather than routinely screening all men in this group. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women ages 65 to 75 years who have ever smoked. The USPSTF recommends against routine screening for AAA in women who have never smoked. (Release Date: August 2014)

Carotid Artery Stenosis Screening: The USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population. (Release Date: September 2014)

Chlamydia and Gonorrhea Screening: The USPSTF recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection. The USPSTF recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (Release Date: December 2014)

Cognitive Impairment in Older Adults Screening: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment. (Release Date: June 2014)

Dental Caries in Children from Birth through Age 5 Years Screening: The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (Release Date: June 2014)

Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors – Behavioral Counseling: The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. (Release Date: October 2014)

Hepatitis B Virus Infection Screening, 2014: The USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection. (Release Date: July 2014)

Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality from Preeclampsia — Preventive Medication: The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. (Release Date: December 2014)

Sexually Transmitted Infections — Behavioral Counseling: The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). (Release Date: December 2014)

As I mentioned above, the USPTF recommendations frequently differ from clinical practice guidelines produced by other organizations. In my experience, the various primary care medical and affiliated practitioner organizations (American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, etc) generally endorse the USPTF recommendations. However such reputable groups as U.S. medical specialty societies and governmental bodies in other countries do publish dissenting recommendations to the health professionals and the public regarding important issues such as breast and prostate cancer screening. A good source of clinical practice guideline information is the National Guidelines Clearinghouse, also provided free of charge by the Federal AHRQ. I applied advanced search filters with limits of “prevention” and “US-based organizations” only and found over 700 guidelines!

Many of these are not directly applicable to primary care practice, but our patients certainly hear about many of these prevention recommendations through media reports, friends, family, or contact with other healthcare providers. I have dealt with the issue of “when the experts disagree, what’s a PCP supposed to do?” in one of my previous articles published in Primary Issues™: Clinical Guidelines Noncompliance.

 

Charles Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA

 

Published on May 12, 2015