American Academy of Family Physicians Summary of Recommendations for Clinical Preventive Services Jennifer Frost, MD, FAAFP Bellinda K. Schoof, MHA, CPHQ Pamela Carter-Smith, MPA Conference on Practice Improvement December 4, 2015 L27- 4:00-5:00pm

Disclosures Medical Director, Health of the Public and Science Division Director, Health of the Public and Science Clinical Policies Strategist, Health of the Public and Science No Conflicts of Interest to Disclose

Acknowledgments & Gratitude AAFP Commission on Health of the Public and Science AAFP Board of Directors U.S. Preventive Services Task Force(USPSTF) Janet Leiker, RN, MPH, Clinical Policies Manager, AAFP

OBJECTIVES Learn about the history and benefits of AAFP’s Summary of Recommendations for Clinical Preventive Services Have an understanding of how the AAFP applies rigorous analysis of scientific evidence into the Summary of Recommendations for Clinical Preventive Services Learn how to implement screening, chemoprophylaxis and counseling recommendations into your practice

Family Medicine AAFP Membership – 120,900 family physician members Family medicine is the most versatile of all physician specialties, providing comprehensive medical care to patients of all ages. Approximately one in four of all office visits are made to family physicians. That is 214 million office visits each year — nearly 74 million more than the next largest medical specialty.

Family Medicine Family physicians deliver care in a variety of settings, including: – Office practices – Hospitals – Nursing homes – Community health centers – Urgent care centers – Emergency rooms – University-based health centers Family physicians deliver a range of acute, chronic, and preventive medical care services while providing patients with a patient-centered medical home.

AAFP’s Clinical Guidance Development Oversight by AAFP’s Board of Directors and Commission on Health of the Public and Science Utilize an evidence-based methodological approach. Family medicine, whole-person perspective. Develop clinical guidance through:  Clinical Preventive Services Recommendations  Clinical Practice Guidelines  Choosing Wisely Campaign The AAFP’s clinical guidance is widely promoted to family physicians through venues such as:  Continuing Medical Education  Educational Programming  Journals  Website  Promotional Opportunities

Importance of Clinical Preventive Services Clinical preventive services, such as routine disease screening and scheduled immunizations, are key to reducing death and disability and improving the Nation’s health. Despite the fact that these services are covered by the Affordable Care Act, millions of children, adolescents, and adults go without clinical preventive services. Many of the strongest predictors of health and well-being fall outside of the medical care setting. Social, economic, and physical environmental factors all influence health. For example, educational attainment, stable employment, safe homes and neighborhoods, and access to appropriate clinical preventive services tend to affect health positively.

Importance of Clinical Preventive Services Offers tremendous opportunity to save years of life and to help people live better during those years. Science-based prevention can save money—and provide high-quality care—by helping people avoid unnecessary tests and procedures. Evidence-based preventive services are effective in reducing death, disability, and disease, including:  Certain cancers, such as colorectal cancer, breast cancer, and cervical cancer  Chronic diseases, such as heart disease and diabetes  Infectious diseases, such as influenza, chicken pox, and pneumonia  Mental health conditions and substance abuse  Vision disorders

AAFP’s Process POLICY DEVELOPMENT The AAFP develops evidence-based policy recommendations to assist family physicians in making clinical decisions regarding the care of their patients STARTING POINT FOR RECOMMENDATIONS Rigorous analysis of scientific knowledge available as presented by the United States Preventive Services Task Force (USPSTF) INFORM MEMBERS AAFP created the “Summary of Recommendations for Clinical Preventive Services (RCPS),” a compendium of evidence-based recommendations

CLINICAL GUIDANCE  The summary of policy recommendations began with development of the Age Charts for Periodic Health Examination, in 1995  The Summary of Policy Recommendations for Periodic Health Examination, implemented 1996  In 2006 the Summary of Recommendations for Clinical Preventive Services was implemented.  The Summary of Recommendations for Clinical Preventive Services is a tool to educate family physicians and their practice staff about evidence-based recommendations _care/clinical_recommendations/cps- recommendations.pdf Preventive Services

CLINICAL GUIDANCE Preventive Services About Choosing Wisely® The Choosing Wisely®( campaign was created as an initiative of the American Board of Internal Medicine (ABIM) Foundation( org) to improve health care quality. More than 70 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused.Choosing Wisely®( Board of Internal Medicine (ABIM) Foundation( org)

CLINICAL GUIDANCE Preventive Services Immunizations AAFP collaborates at the national level with the Centers for Disease Control and Prevention (CDC), its Advisory Committee on Immunization Practices (ACIP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American College of Obstetricians and Gynecologists (ACOG) in the development of the yearly national child, adolescent and adult immunization recommendations. The AAFP influences recommendations at the national level through its liaison to the ACIP and family physician representation on ACIP Immunization Working Groups. The Recommended Immunization Schedules are updated annually and are posted to the AAFP Immunization webpage ( nres.html). nres.html

Clinical Practice Guidelines  The AAFP develops evidence-based clinical practice guidelines (CPGs), which serve as a framework for clinical decisions and supporting best practices. Clinical practice guidelines are statements that include recommendations intended to optimize patient care.  Informed by a systematic review of evidence, and an assessment of the benefits and harms of alternative care options. CPGs should follow a sound, transparent methodology to translate best evidence into clinical practice for improved patient outcomes. Additionally, evidence-based CPGs are a key aspect of a patient-centered medical home (PCMH).  A list of AAFP’s Clinical Practice Guidelines are located at: practice-guidelines.html practice-guidelines.html

Clinical Practice Guidelines Evidence-Based Methodology  Clinical practice guidelines should be feasible, measurable, and achievable.  Clinical practice guidelines, from which quality performance measures will be developed, should be reviewed by representatives of the physicians they will impact.  Clinical performance measures may be developed from clinical practice guidelines and used in quality improvement initiatives. When these performance measures are incorporated into public reporting, accountability, or pay for performance programs, the strength of evidence and magnitude of benefit should be sufficient to justify the burden of implementation.  In the clinical setting, implementation of clinical practice guidelines should be prioritized to those that have the strongest supporting evidence, and the most impact on patient population morbidity and mortality.  Research should be conducted on how to effectively implement clinical practice guidelines, and the impact of their use as quality measures.  Clinical practice guidelines, from which quality performance measures have been developed, should be updated as new evidence is available, and the producers of the performance measures should be notified of the work in progress. The AAFP develops clinical practice guidelines using rigorous evidence-based methodology with the strength of evidence for each guideline explicitly stated.

Clinical Practice Guidelines Training/Manual  Clinical practice guidelines are state­ments that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.  Rather than dictat­ing a one-size-fits-all approach to patient care, clinical practice guidelines offer an evaluation of the quality of the relevant scientific literature, and an assessment of the likely benefits and harms of a particular treatment. This information enables health care clinicians to select the best care for a unique patient based on his or her preferences.  AAFP’s Commission on Health of the Public and Science (CHPS) and Board of Directors provides oversight for the development and approval of its clinical practice guidelines.  Principles for Development (IOM 1.1, CMSS-P 11, CMSS-C): The IOM identified eight standards for developing trustworthy guidelines. The standards reflect best practices across the entire guideline development process.  To access the AAFP’s Clinical Practice Guideline Manual and the IOM standards please visit:

 The Summary of Recommendations for Clinical Preventive Services was created to assist physicians in making clinical decisions based on the evidence  AAFP’s RCPS is periodically updated through the AAFP’s Commission on Health of the Public and Science (CHPS)  AAFP Board of Directors approved Process of Development AAFP Summary of Recommendations for Clinical Preventive Services

Process of Development o The AAFP’s Clinical Preventive Services recommendations are for screening, chemoprophylaxis and counseling. They do not apply to patients who are at increased risk or have signs and/or symptoms related to a particular condition.

AAFP Summary of Recommendations for Clinical Preventive Services Process of Development U.S. Preventive Services Task Force (USPSTF) 16 volunteer members – Family Medicine, Internal Medicine, OB/GYN, Pediatrics, Nursing, Behavioral Medicine Recommendations address only services offered in the primary care setting or services referred by a primary care clinician Supported by the Agency for Health Research and Quality (AHRQ)

AAFP Summary of Recommendations for Clinical Preventive Services Process of Development U.S. Preventive Services Task Force (USPSTF) Topic NominationResearch PlanEvidence Review

Certainty of Net BenefitMagnitude of Net Benefit SubstantialModerateSmallZero/Negative HighABCD ModerateBBCD LowInsufficient

AAFP Summary of Recommendations for Clinical Preventive Services Process of Development Grading Definition A Recommendation: The AAFP recommends the service. There is high certainty that the net benefit is substantial. B Recommendation: The AAFP recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C Recommendation: The AAFP recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. D Recommendation: The AAFP recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I Recommendation: The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

AAFP Summary of Recommendations for Clinical Preventive Services Process of Development U.S. Preventive Services Task Force (USPSTF) Draft recommendation Final recommendation

AAFP Summary of Recommendations for Clinical Preventive Services The CHPS reviews recommendations released by the USPSTF and makes recommendations to the AAFP Board of Directors, in most cases the AAFP agrees with the USPSTF, however, there are circumstances where there are differences. EXAMPLES AMERICAN ACADEMY OF FAMILY PHYSICIANSUS PREVENTIVE SERVICES TASK FORCE Lung Cancer Grade: I recommendation The AAFP concludes that the evidence is insufficient to recommend for or against screening for lung cancer with low- dose computed tomography (LDCT) in persons at high risk for lung cancer based on age and smoking history. (2013) Lung Cancer Grade: B recommendation The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. HIV Infection, Adolescents and Adults Grade: A recommendation The AAFP recommends that clinicians screen adolescents and adults ages 18 to 65 years for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened. See the Clinical Considerations for more information about screening intervals. (2013) HIV Infection, Adolescents and Adults Grade: A The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Process of Development

AAFP Summary of Recommendations for Clinical Preventive Services Promotion and Dissemination The AAFP has developed the Clinical Recommendations applet. Download the AAFP app for your iPhone or iPad from the iTunes Store (itunes.apple.com). To add the app to your Android device, download it from Google Play (play.google.com). Here’s just some of what you can do with the new app: Search: AAFP’s Clinical Preventive Services recommendations; Clinical Practice Guidelines, and Choosing Wisely® Recommendations Make evidence-based decision about the treatment and prevention of diseases with AAFP clinical recommendations, sortable by topic or title Get access to up-to-date information on children, adolescent and adult immunizations including interactive charts, FAQ’s, laws and regulations, and coding resources AAFP Clinical Recommendations Applet

AAFP Summary of Recommendations for Clinical Preventive Services Promotion and Dissemination AAFP Clinical Preventive Services recommendations are located on the Patient Care website: AAFP Website: Patient Care

AAFP Summary of Recommendations for Clinical Preventive Services Promotion and Dissemination AAFP Communications The AAFP News will often communicate the release of Clinical Preventive Service Recommendations from the USPSTF and the AAFP: public.htmlhttp:// public.html

AAFP Summary of Recommendations for Clinical Preventive Services Promotion and Dissemination Family Medicine Experience (FMX)  The AAFP promotes and disseminate clinical preventive services recommendations at FMX through CME courses, "U.S. Preventive Services Task Force Updates” ments/events/fmx/handouts/ pdf ments/events/fmx/handouts/ pdf  The Health of the Public and Science(HOPS) exhibit booth

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