PEDIATRICS Vol. 122 No. 1 July 2008, pp. 174-176 (doi:10.1542/peds.2008-0869)
COMMENTARY |
Pediatricians and the US Preventive Services Task Force: A Natural Partnership to Enhance the Health of Children
a Department of Pediatrics, Baylor College of Medicine, Houston, Texas
b Department of Pediatrics, Georgetown University, Washington, DC
Abbreviations: USPSTF, US Preventive Services Task Force • AHRQ, Agency for Healthcare Research and Quality • AAP, American Academy of Pediatrics
IN THIS ISSUE of Pediatrics, readers will find the recommendation of the US Preventive Services Task Force (USPSTF) that all newborns be screened for hearing loss1; readers will also find a concise version of the systematic evidence report that was commissioned to help develop this recommendation.2 Over the last several years, Pediatrics has published 5 recommendations relevant to children from the USPSTF3–7 and plans to publish additional recommendations as they are released. Because many pediatricians know very little about the USPSTF,8 we would like to use this commentary to inform readers about this task force: what it is, who is involved, how it works, and what readers can expect from these publications.
The USPSTF is an independent panel charged by the US Congress to review the scientific evidence for clinical preventive services and develop evidence-based recommendations for the health care community. It was first convened by the US Public Health Service in 1984 and, since 1998, has been sponsored by the Agency for Healthcare Research and Quality (AHRQ). The USPSTF comprises 16 private-sector experts in prevention and primary care, representing primary care specialties and nursing, who serve for terms of 4 to 6 years.
Members of the USPSTF are nominated by federal agencies, partner organizations (such as the American Academy of Pediatrics [AAP]), and individuals in response to an announcement in the Federal Register. Members are chosen for their ability to make rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications, and synthesize these assessments into recommendations. Throughout its existence, the task force has had at least 2 pediatricians, as well as other pediatric health care providers, among its members. Currently, 3 of its 16 members are pediatricians, and a fourth is a pediatric nurse practitioner. Liaisons from the major primary care societies, including the AAP, and various US Public Health Service agencies contribute their expertise to the evaluation process, provide peer review of draft documents, and help disseminate the work of the task force to their members.
The task force focuses on preventive services that are either provided in primary care settings or are available through primary care referral to prevent conditions of substantial health burden in the United States. The main audience for USPSTF recommendations is the primary care clinician, but policy makers, researchers, and, of course, patients also have a stake in its recommendations.
The USPSTF adheres strongly to a policy of making recommendations only in the presence of at least moderate certainty of benefit, based on published evidence, even for practices that may currently be supported by expert consensus or less rigorous evidence. Because it sets a high bar for evidence, the task force process produces a more limited set of recommendations for preventive services than are produced by many other groups. When the evidence is insufficient, the task force does not make a recommendation but, rather, issues an "I statement," which indicates that the evidence reviewed was not strong enough to support a positive or negative recommendation. Some recommendations for clinical preventive services also fall within the scope of other federal agencies. For example, adult and childhood immunizations are addressed by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices. In these instances, the task force will often choose to defer to such recommendations.
Readers should understand what the USPSTF does and does not do. It does not provide a comprehensive guide to well-child care or to child health supervision, both of which properly involve more than clinical preventive services. It also does not address the entire range of community-based prevention activities that pediatricians may help to lead. Pediatricians may want to refer to the Centers for Disease Control and Prevention Community Task Force for guidance about the evidence for community-wide health-promotion and disease-prevention activities.
Topics for the USPSTF are solicited biennially from the public (by a notice in the Federal Register), from partner organizations, and from task force members. Nominated topics that fit within the task force's scope are prioritized on the basis of the public health importance of the condition to be prevented, the expected effectiveness of the preventive service, the potential for the task force to have an effect on clinical practice, and the need to balance the portfolio of topics. In the past, the task force has not addressed as many child health–related topics as pediatricians would prefer, but as more high-quality evidence is available and as stakeholders ask for guidance, this has begun to change. In fact, the majority of statements released by the USPSTF in 2006 were related to child health. Examples of topics that are currently under review include screening for depression in children and adults, screening for dental caries in preschool-aged children, and screening for diabetes in adults.
How does the task force review the evidence and make a recommendation? Once a topic has been chosen, an analytic framework is developed to describe the relationship between the preventive intervention and important health outcomes (Fig 1). Key questions for describing each step in the framework help to delineate the evidence search that is required to assess the effectiveness of the service and make a recommendation. The systematic evidence reviews on which the USPSTF bases its recommendations are commissioned by the AHRQ and performed by experts in evidence review at AHRQ-funded evidence-based practice centers. All systematic evidence reviews follow the same established and transparent methodology, which includes comprehensive evidence searching, critical appraisal of available studies, and synthesis of the evidence. A detailed description of these methods is available on the AHRQ Web site (www.ahrq.gov/clinic/uspstmeth.htm).
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Evidence is rated according to a carefully defined scale that gives greater weight to study designs that are less vulnerable to bias or confounding. Well-designed, randomized, clinical trials, for example, have greater weight on this scale than case-control or cohort studies, which in turn have more weight than case reports or uncontrolled trials. Expert opinion alone, if unsupported by published scientific studies, rarely receives any consideration. The task force does, however, incorporate expert and peer review of its background documents to confirm that all relevant literature has been considered and that the evidence presented for consideration is accurate.
When the evidence review is complete and has undergone peer review and revision, it is presented to the USPSTF. The task force assesses the available evidence and assigns a grade to each specific statement it issues: A (recommends), B (recommends), C (recommends against routine use), D (recommends against), or I (insufficient evidence to recommend for or against). The final assessment of the certainty of the evidence and the magnitude of the relative potential for benefit and harm are the responsibility of the USPSTF and do not represent the opinion of any federal agency. Recommendations are updated every 5 years or sooner if new evidence becomes available that could substantially change a recommendation. The recommendation for newborn hearing screening published in this issue of Pediatrics is an update of a previous I statement. When new evidence became available, the task force reviewed the evidence and changed the recommendation to reflect the improved health outcomes that had been demonstrated in good-quality studies.
The process used by the task force differs significantly from that used by the AAP and many other professional organizations. Professional organizations are called on by members to provide specific and complete recommendations for practice, which often requires using expert consensus when evidence is lacking. Two recent policies of the AAP address this process, one on guideline development and another on transparency in clinical policies of all types.9,10
What should readers expect from a USPSTF recommendation? Each recommendation statement is designed to concisely address specific key issues including the importance of the condition, detection, benefits and harms of early detection and treatment, and critical gaps in knowledge. In addition to the recommendation itself, the statement includes a structured rationale that briefly summarizes the evidence and the reasoning behind the recommendation. A section entitled "Clinical Considerations" includes guidance about ways to provide or offer the preventive service in the clinical setting. Finally, key gaps in the evidence and priorities for future research and research funding are identified.
How can pediatricians get involved? The USPSTF functions best when those for whom the recommendations are intended are involved in the process. Pediatricians can respond to the periodic Federal Register announcements to nominate members or suggest a topic. AAP committees and sections are frequently asked to provide expert review of the drafts of evidence reports and recommendation statements. The thoughtful reviews that the AHRQ evidence-based practice centers and the USPSTF receive from partner organizations such as the AAP are considered carefully in the process of developing recommendations. I statements, which unfortunately are common for pediatric topics, are obvious indicators of research gaps that are ripe for investigation.
The AHRQ and USPSTF have serious concerns that pediatric health care providers in particular have limited knowledge of the USPSTF review process and recommendations. In a survey of practicing pediatricians, only 16% were aware that these guidelines existed.8 In addition, even when pediatricians are aware of the guidelines, they frequently do not follow them. Recognizing that the guidelines have little value if practitioners are not aware of their existence or do not follow them, the AHRQ is especially interested in translating the research on which these guidelines are based into clinical practice.
Why bother with this effort to create and promote evidence-based preventive care recommendations? Over the last several decades, the importance of careful scientific evaluation of routine preventive care has been recognized. Promotion of services that may be ineffective not only wastes time and money but could also harm healthy patients, divert resources from more important issues, and undermine efforts to determine what services actually affect health. It is our hope that publication of USPSTF recommendations in Pediatrics will help keep AAP members and other readers fully informed about evidence-based recommendations for preventive care for children and adolescents. These publications will also remind us all that we must support research so that we can transform the many I statements in child health into clear, evidence-based recommendations.
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FOOTNOTES |
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Accepted Mar 24, 2008.
Address correspondence to Virginia A. Moyer, MD, MPH, Baylor College of Medicine, Department of Pediatrics, 6621 Fannin St, #1540, Houston, TX 77030. E-mail: moyer{at}bcm.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
Dr Moyer is a member of the USPSTF, and Dr Nelson is the AAP liaison to the USPSTF.
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REFERENCES |
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 TOP REFERENCES |
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- US Preventive Services Task Force. Universal screening for hearing loss in newborns: US Preventive Services Task Force Recommendation Statement.
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[Abstract/Free Full Text] - Nelson HD, Bougatsos C, Nygren P. Universal newborn hearing screening: systematic review to update the 2001 US Preventive Services Task Force recommendation. Pediatrics.2008; 122 (1). Available at: www.pediatrics.org/cgi/content/full/122/1/e266
- US Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement.
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[Abstract/Free Full Text] - US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement.
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[Free Full Text] - US Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women.
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[Free Full Text] - US Preventive Services Task Force. Screening for speech and language delay in preschool children: recommendation statement.
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[Free Full Text] - US Preventive Services Task Force. Screening for lipid disorders in children: US Preventive Services Task Force recommendation statement. Pediatrics.2007; 120 (1). Available at: www.pediatrics.org/cgi/content/full/120/1/e215
- Christakis DA, Rivara FP. Pediatricians' awareness of and attitudes about four clinical practice guidelines.
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[Abstract/Free Full Text] - American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Toward transparent clinical policies.
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[Abstract/Free Full Text] - American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines.
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[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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