Report 6 of the Council on Scientific Affairs (I-01)
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Implementing the Guides to Community Preventive Services

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"His [the physician’s] relationship was formerly to his patient--at most to his patient’s family; and it was almost altogether remedial. The patient had something the matter with him; the doctor was called in to cure it. Payment of a fee ended the transaction. But the physician’s function is fast becoming social and preventive, rather than individual and curative. Upon him society relies to ascertain, and through measures essentially educational to enforce, the conditions that prevent disease and make positively for physical and moral well-being." (Abraham Flexner, 1910) ¹

Resolution 414 (I-00), introduced by the American College of Preventive Medicine and referred to the Board of Trustees, asks:

Relevant AMA Policy

The AMA recommends the US Preventive Services Task Force Guide to Clinical Preventive Services (2^nd edition) to clinicians and medical educators as one resource for guiding the delivery of clinical preventive services. The Guide should not be construed as AMA policy on screening procedures and should not take the place of clinical judgment and the need for individualizing care with patients. (H-410.967, AMA Policy Database)

Prevention should be a philosophy that is espoused and practiced as early as possible in undergraduate medical schools, residency training, and continuing medical education, with heightened emphasis on the theory, value, and implementation of both clinical preventive services and population-based preventive medicine. (H-425.984)

It is the policy of the AMA that: (1) physicians should become familiar with and increase their utilization of clinical preventive services protocols; (2) individual physicians as well as organized medicine at all levels should increase communication and cooperation with and support of public health agencies. Physician leadership in advocating for a strong public health infrastructure is particularly important; (3) physicians should promote and offer to serve on local and state advisory boards; (4) physicians and medical societies should advocate for the adoption of local/state health objectives for the year 2000; and (5) in concert with other groups, physicians should study local community needs, define appropriate health objectives, and work toward achieving health goals for the community. (H-425.986)

The AMA will engage in activities, including but not limited to: educating members on Healthy People 2010 through sponsored continuing medical education events and publications; encouraging state medical societies to engage in promoting activities that address the elimination of health disparities; and investigating the development of a partnership with the Department of Health and Human Services to work to accomplish the goal of eliminating disparities on the basis of race and ethnicity. (H-350.967)

Background

The Task Force on Community Preventive Services (the Task Force) was convened by the Centers for Disease Control and Prevention, US Public Health Service, to identify population-based recommendations (Community Guides) to reduce the risks that contribute to the leading causes of morbidity and premature mortality.² The recommendations are intended to complement the Guidelines for Clinical Preventive Services, which were developed and updated by the US Preventive Services Task Force convened by the Agency for Health Quality and Research.³ Although the Community Guides are primarily intended for use by public health audiences, they will make a major contribution to addressing the spectrum of disease prevention, health policy, and health promotion, including interventions provided within medical settings. The membership of the Task Force is multi-disciplinary, and includes perspectives representative of state and local health departments, managed care, academia, behavioral and social sciences, communications sciences, mental health, epidemiology, quantitative policy analysis, decision and cost-effectiveness analysis, information systems, primary care, and management and policy. Of this group, nine members are physicians.

To understand the rationale for the Community Guides, several working definitions are necessary⁴:

The Task Force will review recommendations in 15 evidence-based topic areas. These are clustered into three themes: Changing Risk Behavior; Reducing Specific Injuries, Diseases, and Impairment; and Addressing Environmental and Ecosystem Challenges:

Changing Risk Behaviors

• Tobacco
• Alcohol
• Other Addictive Drugs
• Physical Activity
• Nutrition
• Sexual Behavior

Reducing Specific Injuries, Diseases, and Impairment

• Vaccine Preventable Diseases
• Cancer
• Diabetes
• Improving Pregnancy Outcomes/Infant Mortality and Health
• Depression and Comorbid Factors
• Motor Vehicle Occupant Injury
• Oral Health
• Violent and Abusive Behavior

Addressing Environmental and Ecosystem Challenges

• Sociocultural Environment

The Task Force used the following inclusion criteria when considering topics: 1) the burden of disease, injury, impairment or exposure; 2) preventability; 3) related initiatives such as the Health Plan Employee Data and Information Set (HEDIS) and Healthy People 2010; and 4) usefulness of the set of topics selected to the target audience.⁴

Each topic area contains a series of recommendations. The recommendations consist of one or more of the following preventive interventions:

• Strategies to educate the general public (eg, mass media) or specific populations (eg, school health education)
• Strategies to mandate compliance (eg, health legislation and regulations)
• Strategies that could be used in the clinical setting to increase delivery of preventive interventions (eg, chart reminders)
• Strategies in health policy designed to improve community health (eg, increasing excise taxes on tobacco products)

Methodology of Guideline Development

Each chapter of the Community Guides is being developed according to a standard protocol.^5,6

1. A multidisciplinary chapter development team is formed that includes 4 to 10 health professionals with methodological or subject matter expertise.
2. A conceptual (eg, logic) framework is developed that maps out the chain of hypothesized causal relations among determinant, intermediate, and health outcomes. The framework is then used to identify explicitly strategic points for actions and the range of preventive interventions that could be directed at these strategic points. The conceptual framework guides the systematic literature reviews.
3. Interventions for evaluation are identified. Since there are usually a variety of possible interventions for each linkage within each conceptual framework, the chapter teams are basing selections of interventions on:

4. Systematic searches of the scientific literature are conducted that meet the inclusion criteria for specificity of intervention and outcome.
5. The evidence on effectiveness for each intervention is assessed by the methodological quality and results of the studies. Two reviewers from each chapter team evaluate the studies, extract the results, summarize the evidence, and assess the strength of the body of evidence. A standardized abstraction form is used that includes 28 questions on content and 23 questions on the quality of the execution of the study. Using a specific set of criteria, study designs are characterized by suitability (eg, greatest, moderate, and least) for assessing the specific intervention under question. Reviewers then evaluate the quality of study execution (eg, good, fair, or limited quality) according to nine limitations. Studies that are evaluated as having limited quality of execution are not used to summarize the body of evidence. Results across a group of related studies are summarized using, when appropriate, quantitative statistical measures to measure variability of data. Finally, "the body of evidence of effectiveness is characterized as strong, sufficient, or insufficient based on the number of studies, the strength of their design and execution, and the size and consistency of report effects."⁶
6. Recommendations are developed from the summary of the body of evidence. The Task Force uses evidence on effectiveness to make a recommendation basically supporting or not supporting each intervention. A judgment is also provided on how widely each recommendation should be applied, as well as commentary on likely barriers to implementing the intervention.
7. Gaps in research are identified.

Progress to Date on Guideline Development

As of the end of August 2001 the Task Force had completed sets of recommendations for the following topics:

Conclusions

It is clear that the Task Force on Community Preventive Services is using a rigorous methodology to develop recommendations for population interventions. It is also clear that these recommendations will be useful to practicing physicians both in their role as direct service providers and their role as advocates within their local communities.

RECOMMENDATIONS

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA directives at the 2001 AMA Interim Meeting:

1. The AMA commends the Centers for Disease Control and Prevention (CDC) and the Task Force on Community Preventive Services for their work in developing the Guides to Community Preventive Services.
2. The AMA will review the recommendations and conclusions of the Task Force on Community Preventive Services and recommend to the House of Delegates the appropriate actions as per AMA policy.
3. The AMA will express to the Director of CDC its support for the establishment of a working group between the CDC and the AMA and the specialty organizations plan for promoting the implementation of the Guides to Community Preventive Services within the private medical sector.
4. The AMA will promote the visibility of the recommendations of the Guides to Community Preventive Services as they become available, provided those recommendations comport with AMA policies and standards.

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References

1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. (1910). Arno Press and the New York Times: New York, NY, 1972.
2. Pappaioanou M , Evans CA Jr. Development of the Guide to Community Preventive Services: A U.S. Public Health Service initiative. J Public Health Management Pract. 1998;4:48-54.
3. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2^nd ed. Baltimore, MD: Williams & Wilkins; 1996.
4. Truman BI, Smith-Akin CK, Hinman AR, Gebbie KM, Brownson R, Novick LF, Lawrence RS, Pappaioanou M, Fielding J, Evans CA, Jr., Guerra F, Vogel-Taylor M, Mahan CS, Fullilove M, Zaza S, Task Force on Community Preventive Services. Developing the Guide to Community Preventive Services—overview and rationale. Am J Prev Med. 2000;18(1S):18-26.
5. Zaza S, Lawrence RS, Mahan CS, Fullilove M, Fleming D, Isham GJ, Pappaioanou M. Task Force on Community Preventive Services. Scope and organization of the Guide to Community Preventive Services. Am J Prev Med. 2000;18(1S):27-34.
6. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Guide to Community Preventive Services-methods. Am J Prev Med. 2000;18(suppl 1):35-43.
7. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med. 2000;18(suppl 1):92-96.
8. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20(2S):10-15.
9. Task Force on Community Preventive Services. Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving. MMWR. 2001;50(RR07):1-13.