Theme articlePriorities Among Effective Clinical Preventive Services: Methods
Introduction
A number of well-known national guidelines outline the clinical preventive services that patients should receive, and are often based on the careful analysis of scientific evidence of effectiveness. For both clinicians and organizational decision makers, however, knowledge that a clinical preventive service is effective is not sufficient to set priorities for increasing the delivery of preventive care. Resources (including clinician and patient time) are limited, and preventive services can differ markedly in their health impact and costs. Clinicians, organizations, and patients need to know which preventive services matter the most. In 2001, a priority ranking of 30 clinical preventive services recommended by the second U.S. Preventive Services Task Force (USPSTF) was presented based on their relative value to the population of the United States.1 Continuously evolving literature and new recommendations by the current USPSTF make the first ranking increasingly outdated. This article describes the approach used to update that ranking.
New studies, new recommendations, and improved methods were used to produce an updated ranking. The 2001 methods2 were adequate for an initial effort to inform priority setting among clinical preventive services, and have been proposed for use in other endeavors.3, 4 However, these new methods take advantage of what was learned previously about data needs and availability, and they address constructive criticisms of the first round, in particular the need for more systematic literature collection and data abstraction.
The National Commission on Prevention Priorities (NCPP), a 30-member panel convened by Partnership for Prevention, and consisting of researchers, health plan executives, employers, and state and federal health officials, guided the study and will guide future updates. The NCPP chose to base the ranking on the same measures used previously, as follows: (1) clinically preventable burden (CPB), which measures a service’s health impact, and (2) cost effectiveness (CE), which measures a service’s economic value.
The scope of the study chosen by the NCPP applied only to primary and secondary preventive services, including immunizations, screening tests, counseling, and preventive medications offered to asymptomatic people in clinical settings. This included (1) clinical preventive services recommended by the USPSTF through December 2004 for the general asymptomatic population and for persons at high risk of coronary heart disease, and (2) immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) through December 2004 for the general population.
The primary challenge of priority setting was deriving consistent estimates of a service’s CPB and cost effectiveness using disparate data. Obvious differences among immunizations, screening, and counseling complicate this task. Preventive services also differ in the size of their target populations, frequency of delivery, and complexity of achieving the intended health benefits.
A related challenge was evidence collection. The literature provided little methodologic direction about collecting and summarizing the many types of data useful to decision makers. In gathering data for their models, authors of many cost-effectiveness studies conduct reviews and summarize data needed for decision making. However, their search strategies and evidence summaries are rarely systematic or well documented. In the previous study, searches were conducted that were similar to comprehensive cost-effectiveness studies. For the current study, standards were developed to ensure a systematic and transparent process for searching, tracking, and abstracting literature for a priority-setting exercise.
These standards are described here for others who wish to use systematic searches to develop comparable information for decision makers. To provide context to these standards and as a reference for those wishing to understand the ranking, methods used to develop consistent CPB and cost-effectiveness estimates are first summarized; these remain largely unchanged from the earlier analysis.2 Readers will find a more detailed discussion of these methods in the previous methods report2 and the complete methods technical report for this update, which is available online.5
Section snippets
Clinically Preventable Burden
Clinically preventable burden was defined as the total quality-adjusted life years (QALYs) that could be gained in a typical practice if the clinical preventive service were delivered at recommended intervals to a U.S. birth cohort of 4 million individuals over the years of life that a service is recommended. This definition has five embedded principles to promote consistency in the estimation of CPB across clinical preventive services.
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Clinically preventable burden should include both
Search Strategies
Because thousands of data points must underlie the priority ranking, and resources and time were limited, there were two primary challenges: (1) devise a search strategy that captures the vast majority of evidence while minimizing the resources spent gathering and evaluating estimates that add little precision to the ranking, and (2) provide transparency for the search strategy.
As a matter of practicality in meeting these objectives, two standardized search strategies were developed, one for
Discussion
These methods differ from the standard approaches used in many systematic literature reviews. In part, this is because many preventive services were evaluated, rather than a single service, not to determine individual effects, but to determine how effective they are relative to others. In addition, a systematic evaluation of cost effectiveness was required. The simplified models demonstrated in the companion articles on colorectal cancer screening, influenza vaccinations, and tobacco-cessation
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