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Since the last Practice Alert update on recommendations made by the US Preventive Services Task Force,1 the Task Force has completed work on 12 topics (TABLE 1).2-17 Five of these topics have been discussed in JFP audio recordings, and the links are provided in TABLE 1.
This latest Task Force endeavor resulted in 18 recommendations (TABLE 2), all of which reaffirm previous recommendations on these topics and expand the scope of 2. There were 2 “A” recommendations, 6 “B” recommendations, 2 “D” recommendations, and 8 “I” statements, indicating that there was insufficient evidence to assess effectiveness or harms. The willingness to make “I” statements when there is little or no evidence on the intervention being assessed distinguishes the USPSTF from other clinical guideline committees.
Screening for carotid artery stenosis
One of the “D” recommendations this past year reaffirms the prior recommendation against screening for carotid artery stenosis in asymptomatic adults—ie, those without a history of transient ischemic attack, stroke, or neurologic signs or symptoms that might be caused by carotid artery stenosis.2 The screening tests the Task Force researched included carotid duplex ultrasonography (DUS), magnetic resonance angiography, and computed tomography angiography. The Task Force did not look at the value of auscultation for carotid bruits because it has been proven to be inaccurate and they do not consider it to be a useful screening tool.
The Task Force based its “D” recommendation on a lack of evidence for any benefit in detecting asymptomatic carotid artery stenosis, and on evidence that screening can lead to harms through false-positive tests and potential complications from carotid endarterectomy and carotid artery angioplasty and stenting. In its clinical considerations, the Task Force emphasized the primary prevention of atherosclerotic disease by focusing on the following actions:
- screening for high blood pressure in adults
- encouraging tobacco smoking cessation in adults
- promoting a healthy diet and physical activity in adults with cardiovascular risk factors
- recommending aspirin use to prevent cardiovascular disease and colorectal cancer
- advising statin use for the primary prevention of cardiovascular disease in adults ages 45 to 75 years who have 1 or more risk factors (hyperlipidemia, diabetes, hypertension, smoking) and those with a 10-year risk of a cardiovascular event of 10% or greater.
This “D” recommendation differs from recommendations made by other professional organizations, some of which recommend testing with DUS for asymptomatic patients with a carotid bruit, and others that recommend DUS screening in patients with multiple risk factors for stroke and in those with known peripheral artery disease or other cardiovascular disease.18,19
Smoking cessation in adults
Smoking tobacco is the leading preventable cause of death in the United States, causing about 480,000 deaths annually.3 Smoking during pregnancy increases the risk of complications including miscarriage, congenital anomalies, stillbirth, fetal growth restriction, preterm birth, and placental abruption.
The Task Force published recommendations earlier this year advising all clinicians to ask all adult patients about tobacco use; and, for those who smoke, to provide (or refer them to) smoking cessation behavioral therapy. The Task Force also recommends prescribing pharmacotherapy approved by the Food and Drug Administration (FDA) for smoking cessation for nonpregnant adults. (There is a lack of information to assess the harms and benefits of smoking cessation pharmacotherapy during pregnancy.)
Continue to: FDA-approved medications...
FDA-approved medications for treating tobacco smoking dependence are nicotine replacement therapy (NRT), bupropion hydrochloride, and varenicline.3 NRT is available in transdermal patches, lozenges, gum, inhalers, and nasal sprays.
In addition, the Task Force indicates that there is insufficient evidence to assess the benefits and harms of e-cigarettes when used as a method of achieving smoking cessation: “Few randomized trials have evaluated the effectiveness of e-cigarettes to increase tobacco smoking cessation in nonpregnant adults, and no trials have evaluated e-cigarettes for tobacco smoking cessation in pregnant persons.”4
Hepatitis B infection screening
The Task Force reaffirmed a previous recommendation to screen for hepatitis B virus (HBV) infection only in adults who are at high risk,5 rather than universal screening that it recommends for hepatitis C virus infection (HCV).7 (See: https://bit.ly/3tt064Q). The Task Force has a separate recommendation to screen all pregnant women for hepatitis B at the first prenatal visit.6
Those at high risk for hepatitis B who should be screened include individuals born in countries or regions of the world with a hepatitis B surface antigen (HBsAg) prevalence ≥ 2% and individuals born in the United States who have not received HBV vaccine and whose parents were born in regions with an HBsAg prevalence ≥ 8%.5 (A table listing countries with HBsAg ≥ 8%—as well as those in lower prevalence categories—is included with the recommendation.5)
HBV screening should also be offered to other high-risk groups that have a prevalence of positive HBsAg ≥ 2%: those who have injected drugs in the past or are currently injecting drugs; men who have sex with men; individuals with HIV; and sex partners, needle-sharing contacts, and household contacts of people known to be HBsAg positive.5
Continue to: It is estimated that...
It is estimated that > 860,000 people in the United States have chronic HBV infection and that close to two-thirds of them are unaware of their infection.5 The screening test for HBV is highly accurate; sensitivity and specificity are both > 98%.5 While there is no direct evidence that screening, detecting, and treating asymptomatic HBV infection reduces morbidity and mortality, the Task Force felt that the evidence for improvement in multiple outcomes in those with HBV when treated with antiviral regimens was sufficient to support the recommendation.
Screening for bacterial vaginosis in pregnancy
While bacterial vaginosis (BV) is associated with a two-fold risk of preterm delivery, treating BV during pregnancy does not seem to reduce this risk, indicating that some other variable is involved.8 In addition, studies that looked at screening for, and treatment of, asymptomatic BV in pregnant women at high risk for preterm delivery (defined primarily as those with a previous preterm delivery) have shown inconsistent results. There is the potential for harm in treating BV in pregnancy, chiefly involving gastrointestinal upset caused by metronidazole or clindamycin.
Given that there are no benefits—and some harms—resulting from treatment, the Task Force recommends against screening for BV in non-high-risk pregnant women. A lack of sufficient information to assess any potential benefits to screening in high-risk pregnancies led the Task Force to an “I” statement on this question.8
Behavioral counseling on healthy diet, exercise for adults with CV risks
Cardiovascular disease (CVD) remains the number one cause of death in the United States. The major risk factors for CVD, which can be modified, are high blood pressure, hyperlipidemia, diabetes, smoking, obesity or overweight, and lack of physical activity.
The Task Force has previously recommended intensive behavioral interventions to improve nutrition and physical activity in those who are overweight/obese and in those with abnormal blood glucose levels,9 and has addressed smoking prevention and cessation.4 This new recommendation applies to those with other CVD risks such as high blood pressure and/or hyperlipidemia and those with an estimated 10-year CVD risk of ≥ 7.5%.10
Continue to: Behavioral interventions...
Behavioral interventions included in the Task Force analysis employed a median of 12 contacts and an estimated 6 hours of contact time over 6 to 18 months.10 Most interventions involved motivational interviewing and instruction on behavioral change methods. These interventions can be provided by primary care clinicians, as well as a wide range of other trained professionals. The Affordable Care Act dictates that all “A” and “B” recommendations must be provided by commercial health plans at no out-of-pocket expense for the patient.
Nutritional advice should include reductions in saturated fats, salt, and sugars and increases in fruits, vegetables, and whole grains. The Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet are often recommended.10 Physical activity counseling should advocate for 90 to 180 minutes per week of moderate to vigorous activity.
This new recommendation, along with the previous ones pertaining to behavioral interventions for lifestyle changes, make it clear that intensive interventions are needed to achieve meaningful change. Simple advice from a clinician will have little to no effect.
Task Force reviews evidence on HTN, smoking cessation in young people
In 2020 the Task Force completed reviews of evidence relevant to screening for high blood pressure11 and
The 2 “I” statements are in disagreement with recommendations of other professional organizations. The American Academy of Pediatrics (AAP) and the American Heart Association recommend routine screening for high blood pressure starting at age 3 years. And the AAP recommends screening teenagers for tobacco use and offering tobacco dependence treatment, referral, or both (including pharmacotherapy) when indicated. E-cigarettes are not recommended as a treatment for tobacco dependence.20
Continue to: The difference between...
The difference between the methods used by the Task Force and other guideline-producing organizations becomes apparent when it comes to recommendations pertaining to children and adolescents, for whom long-term outcome-oriented studies on prevention issues are rare. The Task Force is unwilling to make recommendations when evidence does not exist. The AAP often makes recommendations based on expert opinion consensus in such situations. One notable part of each Task Force recommendation statement is a discussion of what other organizations recommend on the same topic so that these differences can be openly described.
Better Task Force funding could expand topic coverage
It is worth revisiting 2 issues that were pointed out in last year’s USPSTF summary in this column.1 First, the Task Force methods are robust and evidence based, and recommendations therefore are rarely changed once they are made at an “A”, “B”, or “D” level. Second, Task Force resources are finite, and thus, the group is currently unable to update previous recommendations with greater frequency or to consider many new topics. In the past 2 years, the Task Force has developed recommendations on only 2 completely new topics. Hopefully, its budget can be expanded so that new topics can be added in the future.
1. Campos-Outcalt D. USPSTF roundup. J Fam Pract. 2020;69:201-204.
2. USPSTF. Screening for asymptomatic carotid artery stenosis. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
3. USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons. Accessed April 30, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions
4. USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons. JAMA. 2021;325:265-279.
5. USPSTF. Screening for Hepatitis B virus infection in adolescents and adults. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening
6. USPSTF. Hepatitis B virus infection in pregnant women: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-in-pregnant-women-screening
7. USPSTF. Hepatitis C virus infection in adolescents and adults: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening
8. USPSTF; Owens DK, Davidson KW, Krisk AH, et al. Screening for bacterial vaginosis in pregnant persons to prevent preterm delivery: US Preventive Services Task Force recommendation statement. JAMA. 2020;323:1286-1292.
9. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161:587-593.
10. USPSTF. Behavioral counseling interventions to promote a healthy and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2020;324:2069-2075.
11. USPSTF. High blood pressure in children and adolescents: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in-children-and-adolescents-hypertension-screening
12. USPSTF. Prevention and cessation of tobacco use in children and adolescents: primary care interventions. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions
13. USPSTF. Cognitive impairment in older adults: screening. Accessed March 26, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening
14. USPSTF. Illicit drug use in children, adolescents, and young adults: primary care-based interventions. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-primary-care-interventions-for-children-and-adolescents
15. USPSTF. Unhealthy drug use: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening
16. USPSTF. Sexually transmitted infections: behavioral counseling. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/sexually-transmitted-infections-behavioral-counseling.
17. Campos-Outcalt D. USPSTF update on sexually transmitted infections. J Fam Pract. 2020;69:514-517.
18. Brott TG, Halperin JL, Abbara S, et al; ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Catheter Cardiovasc Interv. 2013;81:E76-E123.
19. Ricotta JJ, Aburahma A, Ascher E, et al; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1-e31.
20. Farber HJ, Walley SC, Groner JA, et al; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136:1008-1017.
Since the last Practice Alert update on recommendations made by the US Preventive Services Task Force,1 the Task Force has completed work on 12 topics (TABLE 1).2-17 Five of these topics have been discussed in JFP audio recordings, and the links are provided in TABLE 1.
This latest Task Force endeavor resulted in 18 recommendations (TABLE 2), all of which reaffirm previous recommendations on these topics and expand the scope of 2. There were 2 “A” recommendations, 6 “B” recommendations, 2 “D” recommendations, and 8 “I” statements, indicating that there was insufficient evidence to assess effectiveness or harms. The willingness to make “I” statements when there is little or no evidence on the intervention being assessed distinguishes the USPSTF from other clinical guideline committees.
Screening for carotid artery stenosis
One of the “D” recommendations this past year reaffirms the prior recommendation against screening for carotid artery stenosis in asymptomatic adults—ie, those without a history of transient ischemic attack, stroke, or neurologic signs or symptoms that might be caused by carotid artery stenosis.2 The screening tests the Task Force researched included carotid duplex ultrasonography (DUS), magnetic resonance angiography, and computed tomography angiography. The Task Force did not look at the value of auscultation for carotid bruits because it has been proven to be inaccurate and they do not consider it to be a useful screening tool.
The Task Force based its “D” recommendation on a lack of evidence for any benefit in detecting asymptomatic carotid artery stenosis, and on evidence that screening can lead to harms through false-positive tests and potential complications from carotid endarterectomy and carotid artery angioplasty and stenting. In its clinical considerations, the Task Force emphasized the primary prevention of atherosclerotic disease by focusing on the following actions:
- screening for high blood pressure in adults
- encouraging tobacco smoking cessation in adults
- promoting a healthy diet and physical activity in adults with cardiovascular risk factors
- recommending aspirin use to prevent cardiovascular disease and colorectal cancer
- advising statin use for the primary prevention of cardiovascular disease in adults ages 45 to 75 years who have 1 or more risk factors (hyperlipidemia, diabetes, hypertension, smoking) and those with a 10-year risk of a cardiovascular event of 10% or greater.
This “D” recommendation differs from recommendations made by other professional organizations, some of which recommend testing with DUS for asymptomatic patients with a carotid bruit, and others that recommend DUS screening in patients with multiple risk factors for stroke and in those with known peripheral artery disease or other cardiovascular disease.18,19
Smoking cessation in adults
Smoking tobacco is the leading preventable cause of death in the United States, causing about 480,000 deaths annually.3 Smoking during pregnancy increases the risk of complications including miscarriage, congenital anomalies, stillbirth, fetal growth restriction, preterm birth, and placental abruption.
The Task Force published recommendations earlier this year advising all clinicians to ask all adult patients about tobacco use; and, for those who smoke, to provide (or refer them to) smoking cessation behavioral therapy. The Task Force also recommends prescribing pharmacotherapy approved by the Food and Drug Administration (FDA) for smoking cessation for nonpregnant adults. (There is a lack of information to assess the harms and benefits of smoking cessation pharmacotherapy during pregnancy.)
Continue to: FDA-approved medications...
FDA-approved medications for treating tobacco smoking dependence are nicotine replacement therapy (NRT), bupropion hydrochloride, and varenicline.3 NRT is available in transdermal patches, lozenges, gum, inhalers, and nasal sprays.
In addition, the Task Force indicates that there is insufficient evidence to assess the benefits and harms of e-cigarettes when used as a method of achieving smoking cessation: “Few randomized trials have evaluated the effectiveness of e-cigarettes to increase tobacco smoking cessation in nonpregnant adults, and no trials have evaluated e-cigarettes for tobacco smoking cessation in pregnant persons.”4
Hepatitis B infection screening
The Task Force reaffirmed a previous recommendation to screen for hepatitis B virus (HBV) infection only in adults who are at high risk,5 rather than universal screening that it recommends for hepatitis C virus infection (HCV).7 (See: https://bit.ly/3tt064Q). The Task Force has a separate recommendation to screen all pregnant women for hepatitis B at the first prenatal visit.6
Those at high risk for hepatitis B who should be screened include individuals born in countries or regions of the world with a hepatitis B surface antigen (HBsAg) prevalence ≥ 2% and individuals born in the United States who have not received HBV vaccine and whose parents were born in regions with an HBsAg prevalence ≥ 8%.5 (A table listing countries with HBsAg ≥ 8%—as well as those in lower prevalence categories—is included with the recommendation.5)
HBV screening should also be offered to other high-risk groups that have a prevalence of positive HBsAg ≥ 2%: those who have injected drugs in the past or are currently injecting drugs; men who have sex with men; individuals with HIV; and sex partners, needle-sharing contacts, and household contacts of people known to be HBsAg positive.5
Continue to: It is estimated that...
It is estimated that > 860,000 people in the United States have chronic HBV infection and that close to two-thirds of them are unaware of their infection.5 The screening test for HBV is highly accurate; sensitivity and specificity are both > 98%.5 While there is no direct evidence that screening, detecting, and treating asymptomatic HBV infection reduces morbidity and mortality, the Task Force felt that the evidence for improvement in multiple outcomes in those with HBV when treated with antiviral regimens was sufficient to support the recommendation.
Screening for bacterial vaginosis in pregnancy
While bacterial vaginosis (BV) is associated with a two-fold risk of preterm delivery, treating BV during pregnancy does not seem to reduce this risk, indicating that some other variable is involved.8 In addition, studies that looked at screening for, and treatment of, asymptomatic BV in pregnant women at high risk for preterm delivery (defined primarily as those with a previous preterm delivery) have shown inconsistent results. There is the potential for harm in treating BV in pregnancy, chiefly involving gastrointestinal upset caused by metronidazole or clindamycin.
Given that there are no benefits—and some harms—resulting from treatment, the Task Force recommends against screening for BV in non-high-risk pregnant women. A lack of sufficient information to assess any potential benefits to screening in high-risk pregnancies led the Task Force to an “I” statement on this question.8
Behavioral counseling on healthy diet, exercise for adults with CV risks
Cardiovascular disease (CVD) remains the number one cause of death in the United States. The major risk factors for CVD, which can be modified, are high blood pressure, hyperlipidemia, diabetes, smoking, obesity or overweight, and lack of physical activity.
The Task Force has previously recommended intensive behavioral interventions to improve nutrition and physical activity in those who are overweight/obese and in those with abnormal blood glucose levels,9 and has addressed smoking prevention and cessation.4 This new recommendation applies to those with other CVD risks such as high blood pressure and/or hyperlipidemia and those with an estimated 10-year CVD risk of ≥ 7.5%.10
Continue to: Behavioral interventions...
Behavioral interventions included in the Task Force analysis employed a median of 12 contacts and an estimated 6 hours of contact time over 6 to 18 months.10 Most interventions involved motivational interviewing and instruction on behavioral change methods. These interventions can be provided by primary care clinicians, as well as a wide range of other trained professionals. The Affordable Care Act dictates that all “A” and “B” recommendations must be provided by commercial health plans at no out-of-pocket expense for the patient.
Nutritional advice should include reductions in saturated fats, salt, and sugars and increases in fruits, vegetables, and whole grains. The Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet are often recommended.10 Physical activity counseling should advocate for 90 to 180 minutes per week of moderate to vigorous activity.
This new recommendation, along with the previous ones pertaining to behavioral interventions for lifestyle changes, make it clear that intensive interventions are needed to achieve meaningful change. Simple advice from a clinician will have little to no effect.
Task Force reviews evidence on HTN, smoking cessation in young people
In 2020 the Task Force completed reviews of evidence relevant to screening for high blood pressure11 and
The 2 “I” statements are in disagreement with recommendations of other professional organizations. The American Academy of Pediatrics (AAP) and the American Heart Association recommend routine screening for high blood pressure starting at age 3 years. And the AAP recommends screening teenagers for tobacco use and offering tobacco dependence treatment, referral, or both (including pharmacotherapy) when indicated. E-cigarettes are not recommended as a treatment for tobacco dependence.20
Continue to: The difference between...
The difference between the methods used by the Task Force and other guideline-producing organizations becomes apparent when it comes to recommendations pertaining to children and adolescents, for whom long-term outcome-oriented studies on prevention issues are rare. The Task Force is unwilling to make recommendations when evidence does not exist. The AAP often makes recommendations based on expert opinion consensus in such situations. One notable part of each Task Force recommendation statement is a discussion of what other organizations recommend on the same topic so that these differences can be openly described.
Better Task Force funding could expand topic coverage
It is worth revisiting 2 issues that were pointed out in last year’s USPSTF summary in this column.1 First, the Task Force methods are robust and evidence based, and recommendations therefore are rarely changed once they are made at an “A”, “B”, or “D” level. Second, Task Force resources are finite, and thus, the group is currently unable to update previous recommendations with greater frequency or to consider many new topics. In the past 2 years, the Task Force has developed recommendations on only 2 completely new topics. Hopefully, its budget can be expanded so that new topics can be added in the future.
Since the last Practice Alert update on recommendations made by the US Preventive Services Task Force,1 the Task Force has completed work on 12 topics (TABLE 1).2-17 Five of these topics have been discussed in JFP audio recordings, and the links are provided in TABLE 1.
This latest Task Force endeavor resulted in 18 recommendations (TABLE 2), all of which reaffirm previous recommendations on these topics and expand the scope of 2. There were 2 “A” recommendations, 6 “B” recommendations, 2 “D” recommendations, and 8 “I” statements, indicating that there was insufficient evidence to assess effectiveness or harms. The willingness to make “I” statements when there is little or no evidence on the intervention being assessed distinguishes the USPSTF from other clinical guideline committees.
Screening for carotid artery stenosis
One of the “D” recommendations this past year reaffirms the prior recommendation against screening for carotid artery stenosis in asymptomatic adults—ie, those without a history of transient ischemic attack, stroke, or neurologic signs or symptoms that might be caused by carotid artery stenosis.2 The screening tests the Task Force researched included carotid duplex ultrasonography (DUS), magnetic resonance angiography, and computed tomography angiography. The Task Force did not look at the value of auscultation for carotid bruits because it has been proven to be inaccurate and they do not consider it to be a useful screening tool.
The Task Force based its “D” recommendation on a lack of evidence for any benefit in detecting asymptomatic carotid artery stenosis, and on evidence that screening can lead to harms through false-positive tests and potential complications from carotid endarterectomy and carotid artery angioplasty and stenting. In its clinical considerations, the Task Force emphasized the primary prevention of atherosclerotic disease by focusing on the following actions:
- screening for high blood pressure in adults
- encouraging tobacco smoking cessation in adults
- promoting a healthy diet and physical activity in adults with cardiovascular risk factors
- recommending aspirin use to prevent cardiovascular disease and colorectal cancer
- advising statin use for the primary prevention of cardiovascular disease in adults ages 45 to 75 years who have 1 or more risk factors (hyperlipidemia, diabetes, hypertension, smoking) and those with a 10-year risk of a cardiovascular event of 10% or greater.
This “D” recommendation differs from recommendations made by other professional organizations, some of which recommend testing with DUS for asymptomatic patients with a carotid bruit, and others that recommend DUS screening in patients with multiple risk factors for stroke and in those with known peripheral artery disease or other cardiovascular disease.18,19
Smoking cessation in adults
Smoking tobacco is the leading preventable cause of death in the United States, causing about 480,000 deaths annually.3 Smoking during pregnancy increases the risk of complications including miscarriage, congenital anomalies, stillbirth, fetal growth restriction, preterm birth, and placental abruption.
The Task Force published recommendations earlier this year advising all clinicians to ask all adult patients about tobacco use; and, for those who smoke, to provide (or refer them to) smoking cessation behavioral therapy. The Task Force also recommends prescribing pharmacotherapy approved by the Food and Drug Administration (FDA) for smoking cessation for nonpregnant adults. (There is a lack of information to assess the harms and benefits of smoking cessation pharmacotherapy during pregnancy.)
Continue to: FDA-approved medications...
FDA-approved medications for treating tobacco smoking dependence are nicotine replacement therapy (NRT), bupropion hydrochloride, and varenicline.3 NRT is available in transdermal patches, lozenges, gum, inhalers, and nasal sprays.
In addition, the Task Force indicates that there is insufficient evidence to assess the benefits and harms of e-cigarettes when used as a method of achieving smoking cessation: “Few randomized trials have evaluated the effectiveness of e-cigarettes to increase tobacco smoking cessation in nonpregnant adults, and no trials have evaluated e-cigarettes for tobacco smoking cessation in pregnant persons.”4
Hepatitis B infection screening
The Task Force reaffirmed a previous recommendation to screen for hepatitis B virus (HBV) infection only in adults who are at high risk,5 rather than universal screening that it recommends for hepatitis C virus infection (HCV).7 (See: https://bit.ly/3tt064Q). The Task Force has a separate recommendation to screen all pregnant women for hepatitis B at the first prenatal visit.6
Those at high risk for hepatitis B who should be screened include individuals born in countries or regions of the world with a hepatitis B surface antigen (HBsAg) prevalence ≥ 2% and individuals born in the United States who have not received HBV vaccine and whose parents were born in regions with an HBsAg prevalence ≥ 8%.5 (A table listing countries with HBsAg ≥ 8%—as well as those in lower prevalence categories—is included with the recommendation.5)
HBV screening should also be offered to other high-risk groups that have a prevalence of positive HBsAg ≥ 2%: those who have injected drugs in the past or are currently injecting drugs; men who have sex with men; individuals with HIV; and sex partners, needle-sharing contacts, and household contacts of people known to be HBsAg positive.5
Continue to: It is estimated that...
It is estimated that > 860,000 people in the United States have chronic HBV infection and that close to two-thirds of them are unaware of their infection.5 The screening test for HBV is highly accurate; sensitivity and specificity are both > 98%.5 While there is no direct evidence that screening, detecting, and treating asymptomatic HBV infection reduces morbidity and mortality, the Task Force felt that the evidence for improvement in multiple outcomes in those with HBV when treated with antiviral regimens was sufficient to support the recommendation.
Screening for bacterial vaginosis in pregnancy
While bacterial vaginosis (BV) is associated with a two-fold risk of preterm delivery, treating BV during pregnancy does not seem to reduce this risk, indicating that some other variable is involved.8 In addition, studies that looked at screening for, and treatment of, asymptomatic BV in pregnant women at high risk for preterm delivery (defined primarily as those with a previous preterm delivery) have shown inconsistent results. There is the potential for harm in treating BV in pregnancy, chiefly involving gastrointestinal upset caused by metronidazole or clindamycin.
Given that there are no benefits—and some harms—resulting from treatment, the Task Force recommends against screening for BV in non-high-risk pregnant women. A lack of sufficient information to assess any potential benefits to screening in high-risk pregnancies led the Task Force to an “I” statement on this question.8
Behavioral counseling on healthy diet, exercise for adults with CV risks
Cardiovascular disease (CVD) remains the number one cause of death in the United States. The major risk factors for CVD, which can be modified, are high blood pressure, hyperlipidemia, diabetes, smoking, obesity or overweight, and lack of physical activity.
The Task Force has previously recommended intensive behavioral interventions to improve nutrition and physical activity in those who are overweight/obese and in those with abnormal blood glucose levels,9 and has addressed smoking prevention and cessation.4 This new recommendation applies to those with other CVD risks such as high blood pressure and/or hyperlipidemia and those with an estimated 10-year CVD risk of ≥ 7.5%.10
Continue to: Behavioral interventions...
Behavioral interventions included in the Task Force analysis employed a median of 12 contacts and an estimated 6 hours of contact time over 6 to 18 months.10 Most interventions involved motivational interviewing and instruction on behavioral change methods. These interventions can be provided by primary care clinicians, as well as a wide range of other trained professionals. The Affordable Care Act dictates that all “A” and “B” recommendations must be provided by commercial health plans at no out-of-pocket expense for the patient.
Nutritional advice should include reductions in saturated fats, salt, and sugars and increases in fruits, vegetables, and whole grains. The Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet are often recommended.10 Physical activity counseling should advocate for 90 to 180 minutes per week of moderate to vigorous activity.
This new recommendation, along with the previous ones pertaining to behavioral interventions for lifestyle changes, make it clear that intensive interventions are needed to achieve meaningful change. Simple advice from a clinician will have little to no effect.
Task Force reviews evidence on HTN, smoking cessation in young people
In 2020 the Task Force completed reviews of evidence relevant to screening for high blood pressure11 and
The 2 “I” statements are in disagreement with recommendations of other professional organizations. The American Academy of Pediatrics (AAP) and the American Heart Association recommend routine screening for high blood pressure starting at age 3 years. And the AAP recommends screening teenagers for tobacco use and offering tobacco dependence treatment, referral, or both (including pharmacotherapy) when indicated. E-cigarettes are not recommended as a treatment for tobacco dependence.20
Continue to: The difference between...
The difference between the methods used by the Task Force and other guideline-producing organizations becomes apparent when it comes to recommendations pertaining to children and adolescents, for whom long-term outcome-oriented studies on prevention issues are rare. The Task Force is unwilling to make recommendations when evidence does not exist. The AAP often makes recommendations based on expert opinion consensus in such situations. One notable part of each Task Force recommendation statement is a discussion of what other organizations recommend on the same topic so that these differences can be openly described.
Better Task Force funding could expand topic coverage
It is worth revisiting 2 issues that were pointed out in last year’s USPSTF summary in this column.1 First, the Task Force methods are robust and evidence based, and recommendations therefore are rarely changed once they are made at an “A”, “B”, or “D” level. Second, Task Force resources are finite, and thus, the group is currently unable to update previous recommendations with greater frequency or to consider many new topics. In the past 2 years, the Task Force has developed recommendations on only 2 completely new topics. Hopefully, its budget can be expanded so that new topics can be added in the future.
1. Campos-Outcalt D. USPSTF roundup. J Fam Pract. 2020;69:201-204.
2. USPSTF. Screening for asymptomatic carotid artery stenosis. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
3. USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons. Accessed April 30, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions
4. USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons. JAMA. 2021;325:265-279.
5. USPSTF. Screening for Hepatitis B virus infection in adolescents and adults. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening
6. USPSTF. Hepatitis B virus infection in pregnant women: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-in-pregnant-women-screening
7. USPSTF. Hepatitis C virus infection in adolescents and adults: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening
8. USPSTF; Owens DK, Davidson KW, Krisk AH, et al. Screening for bacterial vaginosis in pregnant persons to prevent preterm delivery: US Preventive Services Task Force recommendation statement. JAMA. 2020;323:1286-1292.
9. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161:587-593.
10. USPSTF. Behavioral counseling interventions to promote a healthy and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2020;324:2069-2075.
11. USPSTF. High blood pressure in children and adolescents: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in-children-and-adolescents-hypertension-screening
12. USPSTF. Prevention and cessation of tobacco use in children and adolescents: primary care interventions. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions
13. USPSTF. Cognitive impairment in older adults: screening. Accessed March 26, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening
14. USPSTF. Illicit drug use in children, adolescents, and young adults: primary care-based interventions. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-primary-care-interventions-for-children-and-adolescents
15. USPSTF. Unhealthy drug use: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening
16. USPSTF. Sexually transmitted infections: behavioral counseling. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/sexually-transmitted-infections-behavioral-counseling.
17. Campos-Outcalt D. USPSTF update on sexually transmitted infections. J Fam Pract. 2020;69:514-517.
18. Brott TG, Halperin JL, Abbara S, et al; ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Catheter Cardiovasc Interv. 2013;81:E76-E123.
19. Ricotta JJ, Aburahma A, Ascher E, et al; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1-e31.
20. Farber HJ, Walley SC, Groner JA, et al; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136:1008-1017.
1. Campos-Outcalt D. USPSTF roundup. J Fam Pract. 2020;69:201-204.
2. USPSTF. Screening for asymptomatic carotid artery stenosis. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening
3. USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons. Accessed April 30, 2021. www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions
4. USPSTF. Interventions for tobacco smoking cessation in adults, including pregnant persons. JAMA. 2021;325:265-279.
5. USPSTF. Screening for Hepatitis B virus infection in adolescents and adults. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-screening
6. USPSTF. Hepatitis B virus infection in pregnant women: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-in-pregnant-women-screening
7. USPSTF. Hepatitis C virus infection in adolescents and adults: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening
8. USPSTF; Owens DK, Davidson KW, Krisk AH, et al. Screening for bacterial vaginosis in pregnant persons to prevent preterm delivery: US Preventive Services Task Force recommendation statement. JAMA. 2020;323:1286-1292.
9. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161:587-593.
10. USPSTF. Behavioral counseling interventions to promote a healthy and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 2020;324:2069-2075.
11. USPSTF. High blood pressure in children and adolescents: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/blood-pressure-in-children-and-adolescents-hypertension-screening
12. USPSTF. Prevention and cessation of tobacco use in children and adolescents: primary care interventions. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions
13. USPSTF. Cognitive impairment in older adults: screening. Accessed March 26, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening
14. USPSTF. Illicit drug use in children, adolescents, and young adults: primary care-based interventions. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-primary-care-interventions-for-children-and-adolescents
15. USPSTF. Unhealthy drug use: screening. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening
16. USPSTF. Sexually transmitted infections: behavioral counseling. Accessed April 30, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/sexually-transmitted-infections-behavioral-counseling.
17. Campos-Outcalt D. USPSTF update on sexually transmitted infections. J Fam Pract. 2020;69:514-517.
18. Brott TG, Halperin JL, Abbara S, et al; ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Catheter Cardiovasc Interv. 2013;81:E76-E123.
19. Ricotta JJ, Aburahma A, Ascher E, et al; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54:e1-e31.
20. Farber HJ, Walley SC, Groner JA, et al; Section on Tobacco Control. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136:1008-1017.
