CHAP ER 8 CLinical Preventive Services (united States Preventive Services Task Force) imbursement; Medicare pays for 93% of recommended clinicians is therefore twofold:(1)find more efficient way reventive services for adults, but the required counseling to deliver preventive services to patients who need them and and coordination are mostly unreimbursed. In a typical (2)discuss goals of care and expected benefits of screening linical practice, urgent problems and symptomatic condi- with patients who are unlikely to benefit. This will probably easily supersede conversations about health require rethinking the delivery of care. No one provider can maintenance. provide the array of preventive services and counseling nec- The Task Force recommends that clinicians track delivery essary in a series of brief, one-on-one encounters. The solu of all services with an A or a B grade for every patient to tion may lie in a team-based model, such as the chronic care ensure that all patients receive these services. Many elec model(see Chapter 28 tronic health records feature reminders at the point of care It is even more difficult to have a meaningful conversation to help providers integrate preventive services. Alternatively, about services that depend on patient preferences for risk, and for paper charts, an assistant can check if the patient is such as those graded c (and some graded B, such as chemo due for recommended services and can prepare screening prevention of breast cancer), or services with conflicting test requisitions in advance. In either case, the time required evidence(graded I). Many patients strongly demand services is considerable. Some authors estimate it would take 7. 4 based on anecdotal evidence from friends, family member hours per workday just to incorporate all recommended ser- or the media. For these services, the Task Force to primary care. This problem might prove intrac community education, use of shared decision ntil the implementation of more innovative care and trained assistants. However, such a sophis odels that link payments to long-term outcomes and personnel-intensive approach is probably not feasible for thereby make prevention an efficient use of practice time many primary care providers (see Chapter 29, Cost Containment Strategies owever, the problem is not only lack of time and reim bursement.Strong evidence also exists for overuse and lll. MAJOR RECOMMENDATIONS misuse of screening services. Medicare reimburses physi cians for 44% of services that have a d rating from the ta A. Highly Recommended Services Force. A large proportion of Medicare patients undergo screening colonoscopies more frequently than recom Table 18-4 lists preventive services that rating of A or mended. Screening is overused in elderly patients and B from USPSTE Recommended services are skewed toward patients in poor health and at the end of life, who screening: About 25 screening services are recommended, unlikely to benefit from screening. The challenge for versus seven counseling services and seven chemoprevention Table 18-4 Recommended Preventive Health Care Screening Services Recommendation Date in Effect Abdominal aortic aneurysm One-time screening for abdominal aortic aneurysm by February 2005 ning: men ultrasonography in men age 65-75 who have ever smoked. Screening and behavioral counseling interventions to reduce alcohol April 2004 misuse by adults, including pregnant women, in primary care Aspirin to prevent cardiovascular 9 when potential benefit of reduction March 2009 disease: mer gastrointestinal hemorrhage. Aspirin to prevent cardiovascular se of aspirin in women age 55-79 when potential benefit of A March 2009 disease. women reduction in ischemic strokes outweighs potential harm of Bacteriuria screening: pregnant Screening for asymptomatic bacteriuria with urine culture for pregnant women at 12-16 weeks gestation or at first prenatal visit, if later Blood pressure screening: adults Screening for high blood pressure in adults age 18 or older. December 2 CA screening bout for deleterious mutations in BRCAI or BRCA2 genes for genetic counseling and evaluation for BRCA testing uly 2002 and at low risk for adverse effects of chemoprevention. Clinicians lould inform patients of potential bene Breast cancer screening Screening mammography for women, with or without clinical breast December 2009 Individualize decision to start mammography earlier than age 50. mber 2009 Breastfeeding counseling e interventions during pregnancy and after birth te