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Rationale for Periodic Reporting on the Use of Selected Adult Clinical Preventive Services — United States

Ralph J. Coates, PhD1

Paula W. Yoon, ScD2

Stephanie Zaza, MD3

Lydia Ogden, PhD4

Stephen B. Thacker, MD5

1Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology, and Laboratory Services

2Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion

3Epidemiology and Analysis Program Office, Office of Surveillance, Epidemiology, and Laboratory Services

4Office of the Associate Director for Policy

5Office of the Director, Office of Surveillance, Epidemiology, and Laboratory Services

Corresponding author: Ralph J. Coates, PhD, Office of Surveillance, Epidemiology, and Laboratory Services, CDC, 1600 Clifton Rd., NE, MS E-97, Atlanta, GA 30333. Telephone: 404-498-0080; Fax: 404-498-0595; E-mail: RCoates@cdc.gov.

Summary

This supplement introduces a CDC initiative to monitor and report periodically on the use of a set of selected clinical preventive services in the U.S. adult population in the context of recent national initiatives to improve access to and use of such services. Increasing the use of these services has the potential to lead to substantial reductions in the burden of illness, death, and disability and to lower treatment costs. The majority of clinical preventive services are provided by the health-care sector, and public health agencies play important roles in helping to support increases in the use of these services (e.g., by identifying and implementing policies that are effective in increasing use of the services and by collaborating with stakeholders to conduct programs to improve use). Recent health reform initiatives, including efforts to increase the accessibility and affordability of preventive services, fund community prevention programs, and improve the use of health information technologies, offer opportunities to enhance use of preventive services. This supplement provides baseline information on a set of selected clinical preventive services before implementation of these recent reforms and discusses opportunities to increase the use of such services. This information can help public health practitioners collaborate with other stakeholders that have key roles to play in improving public health (e.g., employers, health plans, health professionals, and voluntary associations), understand the potential benefits of the recommended services, address the problem of underuse, and identify opportunities to apply effective strategies to improve use and foster accountability among stakeholders.

Clinical Preventive Services

Optimal provision of clinical preventive services has the potential to enable U.S. adults to live longer, healthier lives by reducing the burden of illness, death, and disability (1–5). These services include clinical interventions to reduce the risk for an adverse health condition, screening to identify and treat a condition early to reduce severity and duration, and clinical interventions to reduce complications from a condition or recurrence of a condition (6). Expert panels use multiple methods and procedures to review and evaluate the evidence on the benefits and harms from use of specific clinical preventive services and to develop recommendations (5,7,8). The U.S. Preventive Services Task Force (9), the Advisory Committee on Immunization Practices (ACIP) (10), National Institutes of Health consensus panels (11), and other committees (5) supported by federal agencies make recommendations for clinical preventive services. In addition, associations of health professionals (e.g., the American College of Physicians) and volunteer associations (e.g., the American Diabetes Association) also organize and support panels to issue guidelines (5,12,13).

Approximately half of the U.S. adult population does not use commonly recommended preventive services (1–4,14,15). The Healthy People 2020 initiative, which identifies national objectives for improving population health, reports low levels of use of multiple clinical preventive services recognized as having national importance (16). For example, in 2007, only 8% of ambulatory care physician office visits included counseling or education related to exercise. In 2008, less than half of primary care physicians regularly assessed the body mass index of their adult patients. During 2005–2008, of adults aged ≥18 years with hypertension, 30% were not taking prescribed blood pressure medications.

The health-related costs of underuse of recommended clinical preventive services are substantial. Researchers have reported that increasing use of nine clinical preventive services to more optimal levels (i.e., levels achieved by high-performing health plans) could prevent an estimated 50,000–100,000 deaths each year among adults aged <80 years (4). Another study found that adopting 20 preventive services recommended by the U.S. Preventive Services Task Force could prevent an estimated annual loss in life expectancy for the U.S. population as a whole of approximately 2 million years (3).

Role of Public Health in Clinical Preventive Services

With their focus on population health, public health agencies have played and will continue to play important roles in increasing use of recommended clinical preventive services (17–22). Two long-standing roles for public health are developing policies and plans to improve individual and community health and ensuring provision of health care when it is not otherwise available (17–19). For example, CDC-supported panels make policy recommendations for a range of clinical preventive services including vaccinations of adults and children; counseling, screening, and prevention of human immunodeficiency virus (HIV) and sexually transmitted diseases; and prevention and control of health-care–associated infections (23–25). In addition, public health agencies improve access to clinical preventive services to the broader population by providing services directly, funding the delivery of services through nonprofit community public health clinics, community organizations, or private practices and by providing selected services in nonclinic settings (26–28).

Another important role of public health is identifying community preventive services (i.e., policies, laws, programs and initiatives, education programs, and health system interventions) that are effective in increasing use of clinical preventive services (19,22). To support this function, in 1996, the U.S. Department of Health and Human Services initiated the Community Preventive Services Task Force to examine the effectiveness of a range of community preventive services. The Community Preventive Services Task Force conducts systematic literature reviews to evaluate evidence and uses explicit criteria and procedures to make recommendations (22). Among the community preventive services reviewed and recommended by the Community Preventive Services Task Force are policy and health system interventions that facilitate the delivery of clinical preventive services. These interventions act by reducing patients' out-of-pocket costs (e.g., policies that require no or reduced copayment for clinical preventive services), reducing barriers to access (e.g., through changes in clinic hours or providing services through mobile vans), and using patient tracking systems to identify eligible patients and provide decision support (e.g., patient and provider reminders about the need for and timing of clinical services). In addition, the Community Preventive Services Task Force recommends ongoing surveillance to monitor, evaluate, and report on performance in the use of clinical preventive services, which is an effective and important means of increasing service delivery by clinicians and health plans (22). The Community Preventive Services Task Force also reviews and makes recommendations about policy changes, public health education programs, employee wellness programs, and changes in the physical and social environment to promote use of clinical preventive services and healthy behaviors (e.g., tobacco avoidance, physical activity, weight control, and seatbelt use). Community interventions to promote healthy behaviors have the potential to reduce the need for certain clinical preventive services (e.g., by reducing the prevalence of tobacco use and obesity), thereby decreasing the need for counseling and other clinical interventions.

Public health also plays a critical role in collaborating with other stakeholders to implement effective community interventions to increase use of clinical preventive services. Population health is the outcome not only of services provided by the health-care system and public health agencies but also by the activities of private and voluntary organizations and persons, including employers, health plans, and other stakeholders (17–20). Each stakeholder can implement interventions to increase use of clinical preventive services. CDC has played a leading role in collaborating with stakeholders at the national level and in supporting state and local public health agencies to develop community coalitions to engage in prevention and control programs, including, but not limited to, increasing implementation of interventions recommended by the Community Preventive Services Task Force (24,29,30,31).

Finally, to help other stakeholders plan effective collaborations, public health has a role in monitoring, evaluating, and reporting on how well communities and stakeholders are doing in increasing use of recommended community interventions as well as use of clinical preventive services (20,32). An example of such surveillance is CDC's State Tobacco Activities Tracking and Evaluation (STATE) System, which tracks state tobacco-control policies (33). Monitoring the number and percentage of employers whose employee health insurance policies provide coverage for clinical preventive services recommended by the National Business Group on Health (29) is another example of the type of surveillance that could be conducted. To promote accountability among stakeholders responsible for population health, public health authorities will need to develop additional performance-measurement systems that track specific, effective actions by stakeholders (e.g., worksite wellness programs and use of patient tracking and reminder systems for clinical preventive services) as well as health outcomes (e.g., lower disease rates) (20,32).

Opportunities Offered by Recent Changes to the U.S. Health-Care System

Recent changes in the U.S. health-care system provide opportunities to expand use of preventive services. The Patient Protection and Affordable Care Act of 2010 as amended by the Healthcare and Education Reconciliation Act of 2010 (referred to collectively as the Affordable Care Act [ACA]) emphasizes both population-based prevention and individual clinical preventive services (34–38). Implementation of the Affordable Care Act has the potential to lead to substantial reductions in morbidity, premature mortality, and associated health spending by expanding access to health insurance and increasing use of preventive services (34–38). In 2009, an estimated 58.5 million persons in the United States lacked health insurance for at least some part of the previous 12 months; among adults aged 18–64 years, 25.6% were uninsured for at least part of the year (39). The Congressional Budget Office has estimated that implementation of the Affordable Care Act will extend insurance coverage to 93% of the nonelderly U.S. population by 2016 (38). Medicare now covers adult clinical preventive services graded A (strongly recommended) or B (recommended) by the U.S. Preventive Services Task Force and immunizations recommended by ACIP. These services, together with recommended preventive services for children, youth, and women, will be covered at no cost sharing by newly qualified private health plans in the state-based insurance exchanges that are to start operating in 2014, when a competitive insurance marketplace will be set up in the form of state-based insurance exchanges (ACA §1311). These exchanges will allow eligible persons and small businesses with up to 100 employees to purchase health insurance plans that meet criteria outlined in the Affordable Care Act (34,37). If a state does not create an exchange, the federal government will operate it. Beginning in 2013, state Medicaid programs that eliminate cost sharing for these clinical preventive services might receive enhanced federal matching funds for them (34,35). In addition, Medicare covers an annual wellness visit (which includes a health-risk assessment and a personalized prevention plan) at no cost to beneficiaries. In December 2011, as required by the Affordable Care Act, CDC issued evidence-based guidelines for individualized health-risk assessment (40). Improved insurance coverage, expanded benefits, reduced cost-sharing and improved access to health services can increase use of clinical preventive services (22,29,35). The uninsured are identified frequently as one of the population subgroups with the lowest use of clinical preventive services (41). Even for those who are insured, cost is often a barrier to service use (42). The Affordable Care Act addresses cost impediments to care through additional provisions, including eliminating lifetime and annual limits on private insurance coverage and providing premium rebates if insurers' administrative costs are too high, offering discounted prescription drugs for seniors; providing tax credits for insurance coverage for those from 100%–400% of the federal poverty limit and for small businesses, and extending coverage for young adults up to age 26 years through continued coverage under their parents' insurance plans.

The Affordable Care Act reauthorized the U.S. Preventive Services Task Force (and for the first time authorized the Community Preventive Services Task Force) to continue updating and conducting new reviews, identify research gaps, and make recommendations for evidence-based prevention programs. In addition, the Affordable Care Act created and provided funding for the Prevention and Public Health Fund, which enables communities to prevent the leading causes of death, strengthens state and local disease detection and response, and produces information for action (34–36). In Fiscal Year 2011, CDC was allocated $611 million from the Prevention and Public Health Fund to strengthen prevention, improve the health of the U.S. population, and bolster the ability to detect and respond to both natural and deliberate disease threats. The Affordable Care Act substantially expanded funding for federally qualified community health centers through the Health Resources and Services Administration (HRSA), committing $11 billion over 5 years. It also authorized demonstrations of new payment and care delivery models (e.g., accountable care organizations and community health teams) to promote a population health approach to clinical care (43). Together, these provisions will work to integrate primary care services into community-based mental and behavioral health settings and will support the expansion of the primary care workforce, which can increase access to preventive services (34–36).

Recognizing the importance of broad collaboration for prevention, Congress included the National Prevention Strategy in the Affordable Care Act. Created by the National Prevention, Health Promotion, and Public Health Council in consultation with the public and an advisory group of outside experts, the comprehensive plan, which was released on June 16, 2011, includes specific actions public and private partners can take to help Americans stay healthy (44). The National Prevention Strategy encourages partnerships among federal, state, tribal, local, and territorial governments; business, industry, and other private sector partners; philanthropic organizations; community and faith-based organizations; and individuals to improve health through prevention. It is a cross-sector, integrated national strategy that identifies priorities for improving the health of the U.S. population. Through these partnerships, the National Prevention Strategy aims to improve public health by helping to create healthy and safe communities, expand clinical and community-based preventive services, empower people to make healthy choices, and eliminate health disparities (44).

Other national initiatives that have been implemented in recent years are also likely to increase use of preventive services. The American Recovery and Reinvestment Act (ARRA) of 2009 invested in the expansion of community health centers (45). The portion of ARRA known as the Health Information Technology for Economic and Clinical Health (HITECH) Act, as well as amendments to the Public Health Service Act, support increased use of health information technology as a means of improving the quality, efficiency, and safety of health care (46,47). A draft national strategic plan for health information technology published in 2011 for public comment outlines multiple strategies that have the potential to increase use of preventive services in health care through the use of electronic information technologies (47). The Centers for Medicare and Medicaid Services is offering incentives to providers to increase their use of electronic health information systems and has included selected clinical preventive services as potential quality of care measures (48). Electronic health information systems increase the ability of clinicians and health plans to identify all patients in need of preventive services more easily and systematically, deliver reminders to patients and providers, and assist them in making informed decisions. They also could contribute to evaluating and reporting on the timeliness and quality of care. In addition, by facilitating information exchange, such systems could support patient self-management and improve coordination of care among primary care professionals and specialists. Finally, the new health information technologies together with the other health reform initiatives create opportunities for greater sharing of information and closer collaboration between public health and clinical care professionals to improve the health of the U.S. population.

About This Surveillance Supplement

This surveillance supplement is the first of a series of periodic reports from CDC to monitor and report on progress made at the population level in increasing the use of a set of clinical preventive services identified by CDC as public health priorities. The audience for the report is the broad range of stakeholders who shape the health of the U.S. population, including public health practitioners, employers, health plans, health professionals, and voluntary associations. Before selecting a limited set of clinical preventive services to include in this report, CDC considered a wide range of services and surrogate measures of service use (e.g., proximal biologic outcome measures) to indicate whether a disease is under control. For example, CDC considered a set of adult clinical preventive services that were identified by the Affordable Care Act and that have been evaluated and recommended by the U.S. Preventive Services Task Force or by ACIP (34). Also reviewed were clinical preventive services for areas of public health identified by CDC as priorities, including aspirin therapy, blood pressure and cholesterol control, and smoking cessation (the ABCS for heart disease and stroke prevention) (49) as well as those related to food safety, immunizations, health-care–associated infections, HIV, motor-vehicle injuries, obesity, teen pregnancy, and tobacco use (50).

To select indicators important to the public, stakeholders, and policy makers, CDC identified a set of clinical preventive services that 1) address leading causes of illness, injury, disability, or death; 2) are underutilized but have the potential for substantial increases in use over the next few years with focused effort; 3) have substantial effects on population health, as measured by deaths prevented or healthy life years gained (2–4); 4) are priorities of CDC public health programs and the coalitions of stakeholders; and 5) have routinely collected nationally representative surveillance data available for measurement. Consideration also was given as to whether the same or similar indicators were used by other national efforts to monitor and promote progress in use of clinical preventive services, including Healthy People 2020, the National Quality Forum, and the National Committee for Quality Assurance (16,51,52).

Using these criteria, CDC leadership initiated an iterative process to develop the final list of indicators. A work group that included leaders from multiple CDC programs was formed to develop a proposal; the proposal was then reviewed in more detail by personnel from a broader set of CDC programs and by an external expert work group convened by a member of the Advisory Committee of the Director of CDC.* The work group included leaders in academia, public health, other government agencies, and the private sector. A revised proposal was developed and approved by CDC leadership.

Clinical Preventive Services Indicators

The indicators used in this surveillance supplement address leading causes of death and disability in the United States among adults: heart disease, stroke, cancer, diabetes, influenza, and HIV (13,23,5365) (Table). Also addressed is tobacco use, which is a major contributor to many of those diseases (53–55,62). Most of the indicators are for services recommended by the U.S. Preventive Services Task Force or ACIP, but include others as well. The indicators measure use or biologic effects of preventive services that are underutilized and that, if increased over the next few years, could improve the health of the U.S. population substantially. Improvement in the use of those services is also a focus of public health and community programs as well as national health-care quality improvement efforts.

Given the large number of clinical preventive services recommended for adults, children, or adolescents combined, and recognizing that the set of stakeholders and surveillance systems for adult services differ somewhat from those for adolescent and children's services, CDC decided to limit the scope of this supplement to adult services. A separate supplement covering indicators for clinical preventive services in children is being planned.

For multiple reasons, certain potentially important adult services were not included. For example, the U.S. Preventive Services Task Force does not address food safety specifically and has determined that evidence is insufficient to recommend counseling and other clinical interventions to prevent motor-vehicle injuries, increase physical activity, or counsel most patients to promote a healthy diet, although intensive dietary counseling is recommended for obese adults and those with high cholesterol or cardiovascular disease (9). Obesity screening and alcohol screening are recommended (9), but surveillance data were not available for adequate indicators. Screening for depression also is excluded because current surveillance systems do not have information on the ability of clinician practices to provide effective supportive care for depression. The U.S. Preventive Services Task Force recommends depression screening only when staff-assisted depression care supports are available to assure accurate diagnosis, effective treatment, and follow-up (9). The U.S. Preventive Services Task Force recommends against screening when such supportive care is not available because the benefit of screening depends on the availability of beneficial interventions (9).

Use of This Report

In its 2011 report on the role of measurement in action and accountability in public health (20), the IOM outlined several uses for the kind of information provided in this supplement. The reports in this supplement provide the public and stakeholders responsible for population health (including public health agencies, employers, health plans, health professionals, community groups, and voluntary associations) with easily understood and transparent information about the use of clinical preventive services that can improve population health. Stakeholders can use this information to increase use of these services and to stimulate action, promote responsibility, and hold each other accountable for implementing effective strategies to increase use. In addition, publication of this information on a diverse set of selected adult services in a single supplement offers the opportunity for stakeholders to reduce the burden of both chronic and infectious diseases simultaneously by coordinating efforts when appropriate to increase use of all of these preventive services for all U.S. adults.

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*A list of the members of the two work groups appears on page 78.


Surveillance and Epidemiology Work Group to the Advisory Committee to the Director

Chair: Kelly J. Henning, MD, Public Health Programs, Bloomberg Philanthropies, New York, New York.

Members: Melinda Buntin, PhD, Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services, Washington, District of Columbia; Jac J. Davies, MS, MPH, Inland Northwest Health Services, Spokane, Washington; Paul Halverson, DrPH, Arkansas Department of Health, Little Rock; Sara L. Huston, PhD, Maine Center for Disease Control and Prevention, Augusta; Thomas E. Kottke, MD, HealthPartners Research Foundation, Minneapolis, Minnesota; Jeffrey Levi, PhD, Trust for America's Health, Washington, District of Columbia; Kimberly Rask, MD, PhD, Emory Center on Health Outcomes and Quality, Atlanta, Georgia; Steven Teutsch, MD,, Los Angeles County Department of Public Health, California; Lorna Thorpe, PhD, City University of New York School of Public Health, New York.

Federal Liaison: Ernest Moy, MD, Agency for Healthcare Research and Quality, Rockville, Maryland.

CDC Health Reform Work Group

Chair: Stephen B. Thacker, MD, Office of Surveillance Epidemiology and Laboratory Services.

Members: Peter Briss, MD, Paula Yoon, ScD, National Center for Chronic Disease Prevention and Health Promotion; James W. Buehler, MD, Public Health Surveillance and Informatics Program Office; Janet L. Collins, PhD, Clay Cooksey, M Ed, Donna Knutson, MSEd, George W. Roberts, PhD, Office of the Associate Director for Program; Joanne Cono, MD, Office of Infectious Diseases; Richard J. Klein, MPH, National Center for Health Statistics; Denise Koo, MD, Scientific Education and Professional Development Program Office; Judith A. Monroe, MD, Office for State, Tribal, Local, and Territorial Support; Chesley M. Richards, MD, Office of the Associate Director for Policy; Richard A. Schieber, MD, Stephanie Zaza, MD, Epidemiology and Analysis Program Office, CDC.


TABLE. Selected adult clinical preventive services and the clinical practice recommendation or guideline for the preventive service, by topic, indicator of service use, and issuing organization — United States, 2012

Topic/Indicator

Organization

Aspirin and other antiplatelet therapy

Percentage of adults aged ≥18 years with a history of history of ischemic vascular disease who are prescribed aspirin or other antiplatelet medications to prevent recurrent CVD

ACCP/ACC/AHA*

Percentage of men aged 45–79 years and women aged 55–79 years without ischemic vascular disease who are prescribed aspirin when the potential benefit of a reduction in myocardial infarction or stroke, respectively, outweighs the potential harm attributable to an increase in gastrointestinal hemorrhage

USPSTF

Hypertension management

Percentage of adults aged ≥18 years with hypertension whose blood pressure is under control

JNC7§

Lipid management

Percentage of men aged ≥35 years who have been screened for lipid disorders

USPSTF

Percentage of men aged 20–34 years at increased risk for coronary heart disease who have been screened for lipid disorders

USPSTF

Percentage of women aged ≥45 years at increased risk for coronary heart disease who have been screened for lipid disorders

USPSTF

Percentage of women aged 20–44 years at increased risk for coronary heart disease who have been screened for lipid disorders

USPSTF

Percentage of adults aged ≥20 years with abnormal lipids at increased risk for coronary heart disease who had high LDL cholesterol, were taking lipid-lowering medication, and whose high LDL cholesterol was under control

NCEP**

Diabetes management

Percentage of adults aged ≥18 years with diagnosed diabetes whose glycohemoglobin (A1c) is ≤9%

NDQIA††

Tobacco cessation

Percentage of office-based ambulatory care setting visits with screening for tobacco use among adults aged ≥18 years

USPSTF§§

Percentage of office-based ambulatory care setting visits with tobacco cessation counseling among current tobacco users in adults aged ≥18 years

USPSTF§§

Percentage of office-based ambulatory care setting visits with tobacco cessation medications among current tobacco users in adults aged ≥18 years

USPSTF§§

Percentage of recent smoking cessation success by adult smokers aged ≥18 years, who ever smoked 100 cigarettes, who do not smoke now, and last smoked 6 months to 1 year ago

USPSTF§§

Breast cancer screening

Percentage of women aged ≥40 years who had a mammogram within the previous 2 years

USPSTF¶¶,***

Percentage of women aged 50-74 years who had a mammogram within the previous 2 years

USPSTF¶¶,***

Colorectal cancer screening

Percentage of adults aged 50–75 years who have had a fecal occult blood test (FOBT) within the past year, or sigmoidoscopy within the past 5 years and FOBT within the past 3 years, or colonoscopy within the past 10 years

USPSTF†††

HIV screening

Percentage of persons aged ≥13 years living with HIV who know they are infected

USPSTF¶¶¶/CDC¶¶¶

Influenza vaccination

Percentage of adults aged 18–64 years vaccinated annually against seasonal influenza

ACIP****

Abbreviations: ACC = American College of Cardiology; ACCP = American College of Chest Physicians; ACIP = Advisory Committee on Immunization Practices; ADA = American Diabetes Association; AHA = American Heart Association; CHD = coronary heart disease; CVD = cardiovascular disease; HDL-C = high-density lipoprotein cholesterol; HIV = Human Immunodeficiency Virus; JNC7 = Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; LDL-C = low-density lipoprotein cholesterol; NCEP = National Cholesterol Education Program; NDQIA = National Diabetes Quality Improvement Alliance; TC = total cholesterol; USPSTF = U.S. Preventive Services Task Force.

* Sources: Becker RC, Meade TW, Berger PB, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians evidence-based clinical practice guidelines. 8th ed. Chest 2008;133:776S; Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease, 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113:2363–72.

Source: U.S. Preventive Services Task Force. Aspirin for prevention of cardiovascular disease. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm.

§ Source: National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No. 03-5233. December, 2003.

Source: US Preventive Services Task Force. Screening for lipid disorders in adults, 2008. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm.

** Source: National Heart, Lung, and Blood Institute. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in adults (Adult Treatment Panel III). NIH Publication No. 01-3670. May, 2001.

†† Source: National Diabetes Quality Improvement Alliance. Performance measurement set for adult diabetes. Available at http://www-nehc.med.navy.mil/bumed/diabetes/document%20folders/diabetes/cpg/dqia.msrs.pdf.

§§ Source: US Preventive Services Task. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women, 2009. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm.

¶¶ Source: US Preventive Services Task Force. Screening for breast cancer, 2002. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca2002.htm.

*** Source: US Preventive Services Task Force screening for breast cancer, 2009. Available at http://uspreventiveservicetaskforce.org/uspstf/uspsbrca.htm

††† Source: US Preventive Services Task Force. Screening for colorectal cancer, 2009. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm.

§§§ Source: US Preventive Services Task Force. Screening for HIV, 2007. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm.

¶¶¶ Source: CDC. HIV guidelines and recommendations. Available at http://www.cdc.gov/hiv/resources/guidelines.

**** Source: CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR 2010;59(No. RR-8).


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