The US Preventive Services Task Force

Who Is on the Task Force?

The USPSTF has 16 independent, nonfederal members who serve 4-year terms, led by a chair and 2 vice chairs. Members are nationally recognized experts in prevention and evidence-based medicine and represent the diverse disciplines of primary care, including family medicine, geriatrics, internal medicine, nursing, obstetrics and gynecology, pediatrics, and behavioral health. Most Task Force members are active clinicians who see patients regularly; many are respected researchers and distinguished professors; and all are dedicated to improving the health of Americans. All members volunteer their time to serve on the USPSTF. Task Force members are assigned to working groups that address both individual topics and ongoing development of the methods and processes used by the USPSTF.

Each year, the director of AHRQ appoints new Task Force members to replace those who are completing their service. Any organization or individual can nominate a person for consideration by going to the Task Force Member Nomination page of the AHRQ website. Nominations are welcomed at any time during the year, but they must be received by mid-May to be considered for appointment the following year.

How Are Topics Chosen for Recommendations?

Task Force recommendations focus on interventions to prevent or decrease the severity of disease, and they apply only to people without signs or symptoms of the disease or health condition under consideration. USPSTF recommendations address services offered in the primary care setting or services to which patients can be referred by primary care professionals. The USPSTF makes recommendations about screening tests, counseling about healthful behaviors, and preventive medications to help primary care clinicians, patients, and families decide together whether a particular preventive service is right for an individual's needs. Currently, of 150 statements within 86 active topics, there are 54 statements that recommend preventive services and 26 statements that recommend against particular services; the remainder are statements that the Task Force found inadequate evidence to assess the benefit of the service.

Anyone can nominate a new topic or recommend an update to an existing topic at any time. The USPSTF carefully considers all nominated topics, prioritizing topics based on the topic's relevance to prevention and primary care, its importance for public health, the potential impact of the recommendation, and whether there is new evidence that may change a current recommendation. Once the Task Force selects a topic for review, it follows the process below to develop a recommendation. Each year, the USPSTF considers new topics and updates existing topics.

Once a Topic Is Chosen, How Is a Recommendation Made?

The process starts with the USPSTF and researchers from an evidence-based practice center (EPC) developing a research plan for the topic. EPCs are commissioned by AHRQ to work with the USPSTF to develop evidence reports on specific topics. The research plan includes key questions to be answered and target populations to be considered. The Task Force actively seeks input from those with expertise in the disease or topic being addressed, including medical subspecialists and professional societies, as the work plan is being developed. The draft research plan is posted on the USPSTF website for public comment for 4 weeks, during which time anyone can comment on the plan, including stakeholders and members of the general public. The USPSTF and the EPC review all comments and consider them in revising the research plan.

Using the final research plan as a guide, EPC researchers gather, review, and analyze evidence on the topic from studies published in peer-reviewed scientific journals. The EPC evaluates the internal and external validity of published studies that address key questions and then assigns a quality rating to individual studies (good, fair, or poor) based on established criteria. The EPC summarizes this evidence in a comprehensive evidence report, which is then reviewed by external subject matter experts. In 2013, the USPSTF began sending out draft evidence reports for peer review as well as posting them for public comment for 4 weeks, during which time scientists, researchers, health care professionals, and members of the general public are able to comment. All comments related to the draft evidence report are reviewed by the researchers at the EPC and reported to Task Force members. After this process, the evidence report is revised as necessary.

Task Force members use the evidence report as the basis for their assessment of the effectiveness of the preventive service under consideration. The USPSTF members discuss the evidence and balance the potential benefits against the potential harms in making their recommendations. Potential benefits of clinical preventive services include reduction of risk factors (to prevent disease), early identification of disease (leading to earlier treatment), and ultimately, improved health outcomes such as quality and length of life. Harms of preventive services can include adverse effects of the service itself, as well as the harms of inaccurate test results that may lead to a cascade of additional follow-up tests (some of which are invasive and could cause harm) and unnecessary treatments. Potential harms also include side effects or complications of treatments. When appropriate and when sufficient evidence exists, the USPSTF evaluates the benefits and harms based on age, sex, and risk factors for the disease.

After carefully considering the evidence presented in the draft evidence report, the USPSTF develops a draft recommendation statement based upon its assessment of the potential benefits and harms of the clinical preventive service. The Task Force posts the draft recommendation statement, along with the draft evidence report, for public comment for 4 weeks. The Task Force requests feedback on the completeness of the evidence, its interpretation of the evidence, and the clarity and usefulness of the draft recommendation statement. Members of the Task Force review all comments received on the draft recommendation statement and then revise the recommendation statement as necessary. The final recommendation statement is posted on the USPSTF website, along with the final evidence report and supporting materials. The recommendation statement and a manuscript based on the full evidence review are also usually published in a peer-reviewed medical journal. The USPSTF aims to complete the recommendation process within 12–18 months, but this time frame can vary depending on the size and complexity of the evidence review, the workload of the Task Force, and the number and nature of peer-review and public comments.

Why Such a Focus on the Evidence?

Recommendations for preventive care have evolved over time as it has become widely recognized that some preventive services were not actually beneficial. Recently, the National Academy of Medicine provided important standard guidance regarding the formulation of clinical guidelines and the key foundational attributes of a high-quality guideline process [2]. A rigorous approach to guideline development based on evidence is essential, as research indicates that health care providers are less likely to implement recommendations that are not supported by strong evidence. Also, clinicians presented with recommendations based on insufficient, weak, or poor-quality evidence may face a professional dilemma as they attempt to deliver the highest quality of care. Further, clinical practice variation from lack of rigorously developed guidelines contributes to poor quality care and wasteful health care spending.

The USPSTF makes recommendations based on a rigorous review of existing peer-reviewed evidence. The evidence it uses must be published; it does not use expert or consensus opinion in its deliberations, and the Task Force does not conduct research studies. The USPSTF has very high standards for the evidence it will consider when making a recommendation; poor-quality studies are not admissible evidence in the USPSTF's deliberations.

The USPSTF process for developing guidelines has been repeatedly upheld as an exemplar of rigor and trustworthiness in clinical guideline development. Individual health care providers, professional organizations, integrated health systems, insurers (both private and public), and groups crafting health quality measures and national health objectives have all recognized the need to carefully balance potential benefits and harms using the highest quality of evidence, and many have adopted the recommendations of the USPSTF.

What Is In a Recommendation Statement and How Is It Used?

The recommendation statement includes the recommendation itself, a grade based on the certainty of the evidence and the balance of the potential benefits and harms of the service, the rationale for the recommendation, clinical considerations and other considerations, a discussion of the evidence, and a summary of recommendations of other organizations. See Table 1 for a chart of the letter grades and what they mean. Note that if the evidence does not support either moderate or high certainty, the USPSTF does not make a recommendation but rather issues an “I statement,” signifying that the evidence is insufficient to draw conclusions. Clinical preventive services graded A or B should generally be provided, services graded C may benefit some people based on their individual circumstances, and the Task Force recommends against providing services graded D. The work of the USPSTF is recognized by the Patient Protection and Affordable Care Act of 2010. Under the Affordable Care Act, new health insurance plans or policies must cover preventive services with a USPSTF grade of A or B without cost sharing (eg, copayment or deductible).

Transparency and Engaging the Public

The USPSTF is committed to making its recommendations clear and its work as transparent as possible. As part of this commitment, the Task Force provides multiple opportunities for stakeholders and the public to contribute to the Task Force. Input from stakeholders and the general public is sought in the nomination of USPSTF members, in the nomination of topics for the Task Force to consider, in the development of the work plan at the start of the process for developing a recommendation, in the comments on the draft report from the EPC, and in comments on the draft recommendation statement from the USPSTF. All final documents from the Task Force include a section summarizing the comments and changes that were made as a result of public input. In addition, the USPSTF has enhanced its website to facilitate communication of the time line in the formulation of recommendations and the gathering of public comments.

In addition to engaging the public in the process of making recommendations, the USPSTF is committed to the effective dissemination of these recommendations. To ensure that stakeholders and the public are informed about the recommendations and understand them, the Task Force develops plain language fact sheets on each draft and final recommendation statement, and it works with partner organizations on dissemination and implementation activities.

The work of the USPSTF is informed and strengthened by its partner organizations. These organizations represent primary care clinicians, consumer organizations, federal agencies, and other stakeholders in the delivery of primary care. These partners provide input on topics to be addressed, offer expert review of evidence reports and recommendation statements, and assist with the dissemination of Task Force recommendations. The breadth of scientific and practical expertise of partner organizations helps substantially in increasing the usability and clarity of USPSTF recommendations.

Summary

Since its inception, the USPSTF has made and maintained recommendations on many clinical preventive services that aim to prevent or reduce the risk for heart disease, cancer, infectious diseases, and other conditions and events that impact the health of children, adolescents, adults, and pregnant women. The primary audience for the USPSTF's work remains primary care clinicians, and the recommendations are considered by many to be definitive standards for preventive services. The Guide to Clinical Preventive Services 2014 [3] includes both new and updated recommendations released from 2004–2014 in a brief, user-friendly format meant for use at the point of patient care.

The most up-to-date version of the recommendations, as well as the complete USPSTF recommendation statements, are always available along with their supporting scientific evidence at www.USPreventiveServicesTaskForce.org. To support electronic dissemination of recommendations, the USPSTF also supports an easy-to-use app available on all electronic platforms that contains updated versions of all recommendations; these recommendations can be sorted by recommendation type or by patient characteristics. Individuals can also visit Healthfinder.gov to determine which preventive services they may need based on their age, sex, and health status.