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Increasing suicide rates across the United States are disproportionate among populations most impacted by mass incarceration. We sought to determine if incarceration is associated with risk of suicide and firearm suicide after release from prison.Using a population-based Washington cohort from Department of Corrections and vital statistics administrative records 1990-2017, individuals were compared to the sex-, age-, and race-matched population of Washington using Poisson regression. Among previously incarcerated individuals, we included incarceration history characteristics to calculate sub-hazard ratios using Cox proportional-hazards models.Of 140,281 individuals released from prison, 484 died by suicide. Suicide risk was 62% higher among previously incarcerated individuals compared with the general population (RR: 1.62; 95% CI: 1.46-1.79). Suicide risk was higher among individuals convicted of firearm-involved crimes (RR: 2.27; 95% CI: 1.79-2.89). Individuals released prior to age 18 had substantially higher risk of firearm suicide than those whose first release occurred between ages 18-24 (sHR: 11.91; 95% CI: 4.30-32.96).Our findings highlight the need for improved mental health resources and lethal means safety in this population. Mental health and substance use treatment have been proposed as effective alternatives to incarceration-continuing to study their impacts may reveal additional benefits of reducing suicide.

OBJECTIVE: Addressing firearm access is recommended when patients are identified at risk for suicide. However, the practice of assessing firearm access is controversial and there are no national guidelines to inform practice. This study qualitatively explored patient perspectives on a routine question about firearm access to optimize the patient-centeredness of this practice in the context of suicide risk. METHODS: Electronic health record data was used to identify primary care patients reporting depressive symptoms, including suicidal thoughts, within 2 weeks of sampling. Participants completed a semi-structured telephone interview (recorded and transcribed), which focused broadly on the experience of being screened for suicidality and included specific questions to elicit beliefs/opinions about being asked a standard firearm access question. Directive (deductive) and conventional (inductive) content analysis was used to analyze responses to the portion of the interview focused on firearm assessment and disclosure. RESULTS: A sample of 37 patients in Washington State ages 20–95 completed the qualitative interview by phone. Organizing themes included: 1) Apprehensions about disclosing access to firearms related to privacy, autonomy and firearm ownership rights, 2) Perceptions regarding relevance of the firearm question, informed by experiences with suicidality and common beliefs and misconceptions about the inevitability of suicide, and 3) Suggestions for connecting questions about firearms and other lethal means to suicide risk. CONCLUSION: Clarifying the purpose and use of routine firearm access assessment, contextualizing firearm questions within injury prevention broadly, and addressing misconceptions about suicide prevention may help encourage firearm access disclosure and increase the patient-centeredness of this practice.

Violence has significant impacts on the US health care sector, which include the need to care for injured victims and prevent violence to its physicians and employees, as well as the surrounding community. In 2017 violence resulted in about 2.3 million emergency department visits and 376,500 hospitalizations, with an estimated total medical cost of about $8.7 billion. Victims also often need short- and long-term physical and psychological rehabilitation. Health care workers experience the highest rates of violent injuries in the workplace in the US: 7.8 per 1,000 workers per year, compared to rates under 2.0 per 1,000 for other private industry. Treating and preventing injuries to workers in 2016 added an estimated $429 million in direct and indirect costs to US health systems. Health systems and clinicians have embraced screening and interventions in primary care, mental health care, emergency departments, and other clinical settings to prevent violence among high-risk patients, including potential victims of intimate partner violence, victims of youth violence, and suicidal patients. Some interventions include addressing patients' access to firearms, the most lethal method for assaults and suicides. Community health needs assessments help health systems identify violence as a key community health priority and lead to improvements in the delivery of violence prevention programs.

* Abbreviation: USPSTF — : US Preventive Services Task Force Screening activities aim to identify well-defined diseases at a time when early or presymptomatic identification could lead to better health outcomes compared with identification after symptoms become apparent. For example, newborns are screened for congenital hypothyroidism because they are usually asymptomatic at birth and early detection allows for thyroxine treatment before signs or symptoms develop, leading to the prevention of significant intellectual disability.1 Screening recommendations are formulated around specific conditions with highly specified algorithms and follow-up recommendations for those identified through screening as having the targeted condition. The primary source of preventive services recommendations followed by pediatricians is the American Academy of Pediatrics Bright Futures periodicity schedule, which outlines the specific services to be included as part of routine preventive care for children and adolescents.2 The periodicity schedule includes the recommendations for routine screening (ie, A or B recommendations) from the US Preventive Services Task Force (USPSTF)3 and other recommendations endorsed by the American Academy of Pediatrics, including some screening services for which the USPSTF either has not evaluated or found insufficient evidence to evaluate (ie, I statement). Examples of periodicity schedule recommendations with a USPSTF I statement include screening for autism spectrum disorder, developmental screening, lead screening, and screening for dyslipidemia. The periodicity schedule does not include any preventive services that the USPSTF has recommended against (ie, D recommendations). Screening for targeted conditions at prescribed age intervals is appealing because it facilitates and standardizes the implementation of these preventive services into practice. By screening for … Address correspondence to Alex R. Kemper, MD, MPH, MS, Nationwide Children’s Hospital, 700 Children’s Dr, LAC5411, Columbus, OH 43205-2664. E-mail: alex.kemper{at}nationwidechildrens.org

Author(s): Bibbins-Domingo, K; Grossman, DC; Curry, SJ; Davidson, KW; Jr, Epling JW; Garcia, FAR; Gillman, MW; Kemper, AR; Krist, AH; Kurth, AE; Landefeld, CS; LeFevre, ML; Mangione, CM; Phillips, WR; Owens, DK; Phipps, MG; Pignone, MP

Since the 1980s, the U.S. Preventive Services Task Force (USPSTF) has developed and used rigorous methods to make evidence-based recommendations about preventive services to promote health and well-being for all Americans. Recommendations are based on the evidence of magnitude of net benefit (benefits minus harms). Expert opinion is not substituted when evidence is lacking. Evidence gaps are common. Few preventive services are supported by high-quality studies that directly and comprehensively determine the overall magnitude of benefits and harms in the same study. When assessing the body of evidence, studies may not have been conducted in primary care settings, studies may not have sufficiently included populations of interest, and long-term outcomes may not have been directly assessed. When direct evidence is not available, the USPSTF uses the methodologies of applicability to determine whether evidence can be generalized to an asymptomatic primary care population; coherence to link bodies of evidence and create an indirect evidence pathway; extrapolation to make inferences across the indirect evidence pathway, extend evidence to populations not specifically studied, consider service delivery intervals, and infer long-term outcomes; and conceptual bounding to set theoretical lower or upper limits for plausible benefits or harms. The USPSTF extends the evidence only so far as to maintain at least moderate certainty that its findings are preserved. This manuscript details with examples of how the USPSTF uses these methods to make recommendations that truly reflect the evidence.

The U.S. Preventive Services Task Force (USPSTF) uses an objective evidence-based approach to develop recommendations. As part of this process, the USPSTF also identifies important research gaps in scientific evidence. In March 2016, the USPSTF convened an expert panel to discuss its portfolio of child and adolescent recommendations and identify unique methodologic issues when evaluating evidence regarding children and adolescents. The panel identified key domains of challenges, including measuring patient-centered health outcomes; identifying intermediate outcomes predictive of important health outcomes; evaluating the long time horizon needed to assess the balance of benefits and harms; understanding trajectories of growth and development that result in unique windows of time when expected benefits or harms of a preventive service can vary; and considering the perspectives of other individuals who might be affected by the delivery of a preventive service to a child or adolescent. Although the expert panel expressed an interest in being able to make more recommendations for or against preventive services for children and adolescents, it also reinforced the importance of ensuring recommendations were based on sound and sufficient evidence to ensure greatest benefit and minimize unnecessary harms. Accordingly, the need to highlight areas with insufficient evidence is as important as making recommendations. Having identified these key challenges, the USPSTF and other organizations issuing guidelines have an opportunity to advance their methods of evidence synthesis and identified evidence gaps represent important opportunities for researchers and policy makers.

Purpose Safe firearm storage practices are associated with a lower risk of self-inflicted injury and death. Whether such practices and relevant beliefs differ between households of adolescents with and without mental illness is unknown. Methods We used survey and administrative data to perform a two-stage cross-sectional study of parents/guardians of adolescents who were 11–17 years, enrolled in a managed care plan in 2004 and living in a household with a firearm. Multivariable Poisson models compared the prevalence of three firearm storage practices between households of adolescents with (depression or bipolar disorder) and without mental illness (no psychiatric or substance use disorder), including whether all firearms were locked, any firearms were loaded, and all firearms were locked and unloaded. We used chi-square tests to compare responses to Likert items assessing beliefs relevant to storage practices between households. Results Adolescents with mental illness were present in 141 (50.5%) of 279 study households. Their mean age was 14.5 years, and 54.8% were male. The mean age of parent/guardian respondents was 47.0 years, and 17.9% were male. Respondents from nearly 70% of households reported that all household firearms were stored locked and unloaded. In unadjusted and adjusted analyses, there were no significant differences in the prevalence of three firearm storage practices or in beliefs relevant to those practices between households of adolescents with and without mental illness. Conclusions These findings add to a growing body of evidence suggesting that firearm storage practices do not differ based on household mental health risk factors for self-harm.

Every day in the United States, health professionals confront the effects of firearm injury. In emergency rooms, trauma centers, ambulatory offices, and acute care and rehabilitation facilities, health professionals and the health systems they work within attempt to heal the wounds that firearms can inflict on individuals and their families. Thus, hospitals and health systems are in a position to grasp the scope of the issue and find opportunities to prevent firearm injury and death. In 2016 and 2017, the physicians and nurses at Kaiser Permanente treated more than 3,400 gunshot victims. These patients—from a single health system among the hundreds that operate across the United States—are a sobering reminder of the toll of firearm injury. Firearm injury—including other-directed, self-directed, and unintentional injury and death—is a broad-based public health issue. In 2016, more than 38,000 people were killed by firearms.1 In the same year, half of those who died by suicide used a firearm, and three quarters of homicides involved a firearm.1 Firearm death is the third leading cause of death for children under age 17 in the United States. A social network analysis by Kalesan and colleagues2 showed that almost everyone in the United States, at some point, will know someone injured or killed by a firearm. The nature of the injury varies—homicide is the more likely cause of a firearm death in an urban area, whereas suicide is more likely in a rural area—but every community in every geographic region and every socioeconomic stratum is … Address correspondence to: Questions or comments should be directed to Melissa French at mfrench{at}nas.edu.

Author(s): Bibbins-Domingo, Kirsten; Grossman, David C; Curry, Susan J; Barry, Michael J; Davidson, Karina W; Doubeni, Chyke A; Jr, Epling John W; Kemper, Alex R; Krist, Alex H; Kurth, Ann E; Landefeld, C Seth; Mangione, Carol M; Phillips, William R; Phipps, Maureen G; Silverstein, Michael; Simon, Melissa A; Tseng, Chien-Wen; Force, US Preventive Serv Task

Background: In their landmark report on the “Principles and Practice of Screening for Disease” (1968), Wilson and Jungner noted that the practice of screening is just as important for securing beneficial outcomes and avoiding harms as the formulation of principles. Many jurisdictions have since established various kinds of “screening governance organizations” to provide oversight of screening practice. Yet to date there has been relatively little reflection on the nature and organization of screening governance itself, or on how different governance arrangements affect the way screening is implemented and perceived and the balance of benefits and harms it delivers. Methods: An international expert policy workshop convened by Sturdy, Miller and Hogarth. Results: While effective governance is essential to promote beneficial screening practices and avoid attendant harms, screening governance organizations face enduring challenges. These challenges are social and ethical as much as technical. Evidence-based adjudication of the benefits and harms of population screening must take account of factors that inform the production and interpretation of evidence, including the divergent professional, financial and personal commitments of stakeholders. Similarly, when planning and overseeing organized screening programs, screening governance organizations must persuade or compel multiple stakeholders to work together to a common end. Screening governance organizations in different jurisdictions vary widely in how they are constituted, how they relate to other interested organizations and actors, and what powers and authority they wield. Yet we know little about how these differences affect the way screening is implemented, and with what consequences. Conclusions: Systematic research into how screening governance is organized in different jurisdictions would facilitate policy learning to address enduring challenges. Even without such research, informal exchange and sharing of experiences between screening governance organizations can deliver invaluable insights into the social as well as the technical aspects of governance.

Importance In 2016, approximately 676 000 children in the United States experienced maltreatment (abuse, neglect, or both), with 75% of these children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1700 children died as a result of maltreatment. Objective To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on primary care interventions to prevent child maltreatment. Evidence Review The USPSTF commissioned a review of the evidence on primary care interventions to prevent maltreatment in children and adolescents without signs or symptoms of maltreatment. Findings The USPSTF found limited and inconsistent evidence on the benefits of primary care interventions, including home visitation programs, to prevent child maltreatment and found no evidence related to the harms of such interventions. The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The level of certainty of the magnitude of the benefits and harms of these interventions is low. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement)

Importance More than 35% of men and 40% of women in the United States are obese. Obesity is associated with health problems such as increased risk for coronary heart disease, type 2 diabetes, various types of cancer, gallstones, and disability. Obesity is also associated with an increased risk for death, particularly among adults younger than 65 years. Objective To update the US Preventive Services Task Force (USPSTF) 2012 recommendation on screening for obesity in adults. Evidence Review The USPSTF reviewed the evidence on interventions (behavioral and pharmacotherapy) for weight loss or weight loss maintenance that can be provided in or referred from a primary care setting. Surgical weight loss interventions and nonsurgical weight loss devices (eg, gastric balloons) are considered to be outside the scope of the primary care setting. Findings The USPSTF found adequate evidence that intensive, multicomponent behavioral interventions in adults with obesity can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels; these interventions are of moderate benefit. The USPSTF found adequate evidence that behavior-based weight loss maintenance interventions are of moderate benefit. The USPSTF found adequate evidence that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none. Therefore, the USPSTF concludes with moderate certainty that offering or referring adults with obesity to intensive behavioral interventions or behavior-based weight loss maintenance interventions has a moderate net benefit. Conclusions and Recommendation The USPSTF recommends that clinicians offer or refer adults with a body mass index of 30 or higher to intensive, multicomponent behavioral interventions. (B recommendation)

OBJECTIVE: We assessed the relationship between diabetes mellitus (DM) and measures of worker productivity, direct health care costs, and costs associated with lost productivity among health care industry workers across two integrated healthcare systems. METHODS: We used data from the Value Based Benefit Design Health and Wellness Study Phase II (VBD), a prospective study of employees surveyed across health systems. Survey and healthcare utilization data were linked to estimate lost productivity (LP) and healthcare utilization costs. RESULTS: Mean marginal lost productive time per week was 0.56 hours higher for respondents with DM. Mean adjusted monthly total healthcare utilization costs were $467 higher for respondents with DM. CONCLUSION: The impact of DM is reflected in higher rates of LP and higher indirect costs for employers related to LP and higher healthcare resource use.

Importance In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 11%, and the lifetime risk of dying of prostate cancer is 2.5%. The median age of death from prostate cancer is 80 years. Many men with prostate cancer never experience symptoms and, without screening, would never know they have the disease. African American men and men with a family history of prostate cancer have an increased risk of prostate cancer compared with other men. Objective To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on prostate-specific antigen (PSA)–based screening for prostate cancer. Evidence Review The USPSTF reviewed the evidence on the benefits and harms of PSA-based screening for prostate cancer and subsequent treatment of screen-detected prostate cancer. The USPSTF also commissioned a review of existing decision analysis models and the overdiagnosis rate of PSA-based screening. The reviews also examined the benefits and harms of PSA-based screening in patient subpopulations at higher risk of prostate cancer, including older men, African American men, and men with a family history of prostate cancer. Findings Adequate evidence from randomized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened. Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened. Potential harms of screening include frequent false-positive results and psychological harms. Harms of prostate cancer treatment include erectile dysfunction, urinary incontinence, and bowel symptoms. About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence, and 2 in 3 men will experience long-term erectile dysfunction. Adequate evidence shows that the harms of screening in men older than 70 years are at least moderate and greater than in younger men because of increased risk of false-positive results, diagnostic harms from biopsies, and harms from treatment. The USPSTF concludes with moderate certainty that the net benefit of PSA-based screening for prostate cancer in men aged 55 to 69 years is small for some men. How each man weighs specific benefits and harms will determine whether the overall net benefit is small. The USPSTF concludes with moderate certainty that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older do not outweigh the expected harms. Conclusions and Recommendation For men aged 55 to 69 years, the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening. (C recommendation) The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older. (D recommendation)

Importance Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, 28.7% of community-dwelling adults 65 years or older reported falling, resulting in 29 million falls (37.5% of which needed medical treatment or restricted activity for a day or longer) and an estimated 33 000 deaths in 2015. Objective To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on the prevention of falls in community-dwelling older adults. Evidence Review The USPSTF reviewed the evidence on the effectiveness and harms of primary care–relevant interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency. Findings The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls and that multifactorial interventions have a small benefit. The USPSTF found adequate evidence that vitamin D supplementation has no benefit in preventing falls in older adults. The USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate. Conclusions and Recommendation The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient’s values and preferences. (C recommendation) The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older. (D recommendation) These recommendations apply to community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.

Importance Because of the aging population, osteoporotic fractures are an increasingly important cause of morbidity and mortality in the United States. Approximately 2 million osteoporotic fractures occurred in the United States in 2005, and annual incidence is projected to increase to more than 3 million fractures by 2025. Within 1 year of experiencing a hip fracture, many patients are unable to walk independently, more than half require assistance with activities of daily living, and 20% to 30% of patients will die. Objective To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on vitamin D supplementation, with or without calcium, to prevent fractures. Evidence Review The USPSTF reviewed the evidence on vitamin D, calcium, and combined supplementation for the primary prevention of fractures in community-dwelling adults (defined as not living in a nursing home or other institutional care setting). The review excluded studies conducted in populations with a known disorder related to bone metabolism (eg, osteoporosis or vitamin D deficiency), taking medications known to be associated with osteoporosis (eg, long-term steroids), or with a previous fracture. Findings The USPSTF found inadequate evidence to estimate the benefits of vitamin D, calcium, or combined supplementation to prevent fractures in community-dwelling men and premenopausal women. The USPSTF found adequate evidence that daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium has no benefit for the primary prevention of fractures in community-dwelling, postmenopausal women. The USPSTF found inadequate evidence to estimate the benefits of doses greater than 400 IU of vitamin D or greater than 1000 mg of calcium to prevent fractures in community-dwelling postmenopausal women. The USPSTF found adequate evidence that supplementation with vitamin D and calcium increases the incidence of kidney stones. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in community-dwelling, asymptomatic men and premenopausal women. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with doses greater than 400 IU of vitamin D and greater than 1000 mg of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. (I statement) The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. (D recommendation) These recommendations do not apply to persons with a history of osteoporotic fractures, increased risk for falls, or a diagnosis of osteoporosis or vitamin D deficiency.

Update of the 2007 U.S. Preventive Services Task Force (USPSTF) reaffirmation recommendation statement on screening for high blood pressure in adults.The USPSTF reviewed the evidence on the diagnostic accuracy of different methods for confirming a diagnosis of hypertension after initial screening and the optimal rescreening interval for diagnosing hypertension.This recommendation applies to adults aged 18 years or older without known hypertension.The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. (A recommendation) The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

This paper highlights the collaboration and alignment between topics and recommendations related to behavioral counseling interventions from the U.S. Preventive Services Task Force (USPSTF) and Community Preventive Services Task Force (CPSTF). Although the scope and mandates of the USPSTF and CPSTF differ, there are many similarities in the methods and approaches used to select topics and make recommendations to their key stakeholders. Behavioral counseling recommendations represent an important domain for both Task Forces, given the importance of behavior change in promoting healthful lifestyles. This paper explores opportunities for greater alignment between the two Task Forces and compares and contrasts the groups and their current approaches to making recommendations that involve behavioral counseling interventions. Opportunities to enhance behavioral counseling preventive services through closer coordination when developing and disseminating recommendations as well as future collaboration between the USPSTF and CPSTF are discussed.

The authors estimated the lost productive time (LPT) due to absenteeism and presenteeism among employees at the Group Health Cooperative with controlled and uncontrolled hypertension compared with normotensive patients. The patients responded to a survey inquiring about health behaviors with links to their medical record to identify diagnoses, blood pressure measurement, and prescription drug dispenses. Individuals with controlled hypertension were more likely to report any LPT relative to individuals with uncontrolled hypertension (40.6% vs 32.6%, P

Objectives. We sought to estimate the association between sedative hypnotic use and motor vehicle crash risk. Methods. We conducted a new user cohort study of 409 171 adults in an integrated health care system. Health plan data were linked to driver license and collision records. Participants were aged 21 years or older, licensed to drive in Washington State, had at least 1 year of continuous enrollment between 2003 and 2008, and were followed until death, disenrollment, or study end. We used proportional hazards regression to estimate the risk of crash associated with 3 sedatives. Results. We found 5.8% of patients received new sedative prescriptions, with 11 197 person-years of exposure. New users of sedatives were associated with an increased risk of crash relative to nonuse: temazepam hazard ratio (HR) = 1.27 (95% confidence interval [CI] = 0.85, 1.91), trazodone HR = 1.91 (95% CI = 1.62, 2.25), and zolpidem HR = 2.20 (95% CI = 1.64, 2.95). These risk estimates are equivalent to blood alcohol concentration levels between 0.06% and 0.11%. Conclusions. New use of sedative hypnotics is associated with increased motor vehicle crash risk. Clinicians initiating sedative hypnotic treatment should consider length of treatment and counseling on driving risk.

Importance Menopause occurs at a median age of 51.3 years, and the average US woman who reaches menopause is expected to live another 30 years. The prevalence and incidence of most chronic conditions, such as coronary heart disease, dementia, stroke, fractures, and breast cancer, increase with age; however, the excess risk for these conditions that can be attributed to menopause alone is uncertain. Since the publication of findings from the Women’s Health Initiative that hormone therapy use is associated with serious adverse health effects in postmenopausal women, use of menopausal hormone therapy has declined. Objective To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on the use of menopausal hormone therapy for the primary prevention of chronic conditions. Evidence Review The USPSTF reviewed the evidence on the benefits and harms of systemic (ie, oral or transdermal) hormone therapy for the prevention of chronic conditions in postmenopausal women and whether outcomes vary among women in different subgroups or by timing of intervention after menopause. The review did not address hormone therapy for preventing or treating menopausal symptoms. Findings Although the use of hormone therapy to prevent chronic conditions in postmenopausal women is associated with some benefits, there are also well-documented harms. The USPSTF determined that the magnitude of both the benefits and the harms of hormone therapy in postmenopausal women is small to moderate. Therefore, the USPSTF concluded with moderate certainty that combined estrogen and progestin has no net benefit for the primary prevention of chronic conditions for most postmenopausal women with an intact uterus and that estrogen alone has no net benefit for the primary prevention of chronic conditions for most postmenopausal women who have had a hysterectomy. Conclusions and Recommendation The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal women. (D recommendation) The USPSTF recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal women who have had a hysterectomy. (D recommendation)

Adolescent suicide by firearm imposes devastating losses to families and society, killing more than 1000 10- to 19-year-old children and adolescents annually in the United States. Youth suicide rates between 1999 and 2014 have tripled for 10- to 14-year-olds and increased by 50% for 15- to 24-year-old youth.1 This preventable injury is still a leading cause of death in this age group.2 Household firearms create a suicide (and homicide) risk to all children and adults in a home.3 Given the much higher relative risk to individuals with mental health conditions and substance abuse disorders,4 a focus on families with high-risk adolescents merits top priority. The interaction of guns, mental health, and injury is a topic of national interest. Mainly, the focus is preventing assault injuries and deaths through criminal background checks to restrict gun sales to high-risk individuals. For self-inflicted firearm injury among adults, restrictions are complicated by the challenges of limiting household access. For youth, however, parents and caretakers have a key responsibility in preventing gun access. Exercising this responsibility is critical because self-harm is generally more impulsive and with lower levels of intent in … Address correspondence to David C. Grossman, MD, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101. E-mail: david.c.grossman{at}kp.org

Adults who adhere to national guidelines for a healthful diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not. All persons, regardless of their risk status for cardiovascular disease (CVD), can gain health benefits from healthy eating behaviors and appropriate physical activity.To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention among adults without obesity who do not have cardiovascular risk factors (hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes).The USPSTF reviewed the evidence on whether primary care-relevant counseling interventions to promote a healthful diet, physical activity, or both improve health outcomes, intermediate outcomes associated with CVD, or dietary or physical activity behaviors in adults; interventions to reduce sedentary behaviors; and the harms of behavioral counseling interventions.Counseling interventions result in improvements in healthful behaviors and small but potentially important improvements in intermediate outcomes, including reductions in blood pressure and low-density lipoprotein cholesterol levels and improvements in measures of adiposity. The overall magnitude of benefit related to these interventions is positive but small. The potential harms are at most small, leading the USPSTF to conclude that these interventions have a small net benefit for adults without obesity who do not have CVD risk factors.The USPSTF recommends that primary care professionals individualize the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to promote a healthful diet and physical activity. Existing evidence indicates a positive but small benefit of behavioral counseling for the prevention of CVD in this population. Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling. (C recommendation).

Parents who refuse or delay vaccines because of vaccine hesitancy place children at increased risk for vaccine-preventable disease. How parental vaccine hesitancy changes as their children age is not known. In 2015, we conducted a follow-up survey of 237 mothers enrolled in a 2-arm clinic-level cluster randomized trial (n = 488) in Washington State that was completed in 2013. We surveyed mothers at their baby’s birth, age 6 months, and age 24 months using a validated measure of vaccine hesitancy. Both mean hesitancy scores (mean 4.1-point reduction; 95% CI, 2.5-5.6; P = .01) and the proportion of mothers who were vaccine hesitant (9.7% at baseline vs 5.9% at 24 months; P = .01) decreased significantly from child’s birth to age 24 months. Changes from baseline were similar for first-time mothers and experienced mothers. Individual item analysis suggested that the decrease may have been driven by increases in maternal confidence about the safety and efficacy of vaccines. Our results suggest that hesitancy is a dynamic measure that may peak around childbirth and may remit as experience with vaccines accumulates.

The US Preventive Services Task Force (USPSTF) has issued a draft recommendation statement on screening for prostate cancer, based on an updated systematic evidence review and assessment of the evidence. The full draft recommendation is available for public comment on the USPSTF website1 through May 8, 2017. The USPSTF has proposed the following draft summary language and grade

Importance Preeclampsia affects approximately 4% of pregnancies in the United States. It is the second leading cause of maternal mortality worldwide and may lead to serious maternal complications, including stroke, eclampsia, and organ failure. Adverse perinatal outcomes for the fetus and newborn include intrauterine growth restriction, low birth weight, and stillbirth. Many of the complications associated with preeclampsia lead to early induction of labor or cesarean delivery and subsequent preterm birth. Subpopulation Considerations Preeclampsia is more prevalent among African American women than among white women. Differences in prevalence may be, in part, due to African American women being disproportionally affected by risk factors for preeclampsia. African American women also have case fatality rates related to preeclampsia 3 times higher than rates among white women. Inequalities in access to adequate prenatal care may contribute to poor outcomes associated with preeclampsia in African American women. Objective To update the 1996 US Preventive Services Task Force (USPSTF) recommendation on screening for preeclampsia. Evidence Review The USPSTF reviewed the evidence on the accuracy of screening and diagnostic tests for preeclampsia, the potential benefits and harms of screening for preeclampsia, the effectiveness of risk prediction tools, and the benefits and harms of treatment of screen-detected preeclampsia. Findings Given the evidence that treatment can reduce maternal and perinatal morbidity and mortality, and the well-established accuracy of blood pressure measurements, the USPSTF found adequate evidence that screening for preeclampsia results in a substantial benefit for the mother and infant. In addition, there is adequate evidence to bound the harms of screening for and treatment of preeclampsia as no greater than small. Therefore, the USPSTF concludes with moderate certainty that there is a substantial net benefit of screening for preeclampsia in pregnant women. Conclusions and Recommendation The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. (B recommendation)

The U.S. Preventive Services Task Force (USPSTF) summarizes the principles and considerations that guide development of its recommendations for diverse U.S. populations. It uses these principles through each step in the evidence-based guideline process: developing the research plan, conducting the evidence review, developing the recommendation, and communicating to guideline users. Three recent recommendations provide examples of how the USPSTF has used these principles: the 2015 recommendation on screening for abnormal blood glucose and type 2 diabetes; the 2016 recommendation on screening for breast cancer; and the recommendation on screening for prostate cancer, which is currently in progress. A more comprehensive list of recommendations that includes considerations for specific populations is also provided.

Importance Based on data from the 1990s, estimated prevalence of obstructive sleep apnea (OSA) in the United States is 10% for mild OSA and 3.8% to 6.5% for moderate to severe OSA; current prevalence may be higher, given the increasing prevalence of obesity. Severe OSA is associated with increased all-cause mortality, cardiovascular disease and cerebrovascular events, diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes. Objective To issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for OSA in asymptomatic adults. Evidence Review The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of screening for OSA in asymptomatic adults seen in primary care, including those with unrecognized symptoms. The USPSTF also evaluated the evidence on the benefits and harms of treatment of OSA on intermediate and final health outcomes. Findings The USPSTF found insufficient evidence on screening for or treatment of OSA in asymptomatic adults or adults with unrecognized symptoms. Therefore, the USPSTF was unable to determine the magnitude of the benefits or harms of screening for OSA or whether there is a net benefit or harm to screening. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. (I statement)

Importance Neural tube defects are among the most common major congenital anomalies in the United States and may lead to a range of disabilities or death. Daily folic acid supplementation in the periconceptional period can prevent neural tube defects. However, most women do not receive the recommended daily intake of folate from diet alone. Objective To update the 2009 US Preventive Services Task Force (USPSTF) recommendation on folic acid supplementation in women of childbearing age. Evidence Review In 2009, the USPSTF reviewed the effectiveness of folic acid supplementation in women of childbearing age for the prevention of neural tube defects in infants. The current review assessed new evidence on the benefits and harms of folic acid supplementation. Findings The USPSTF assessed the balance of the benefits and harms of folic acid supplementation in women of childbearing age and determined that the net benefit is substantial. Evidence is adequate that the harms to the mother or infant from folic acid supplementation taken at the usual doses are no greater than small. Therefore, the USPSTF reaffirms its 2009 recommendation. Conclusions and Recommendation The USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400-800 µg) of folic acid. (A recommendation)

Background Value-based insurance designs (VBD) incorporate evidence-based medicine into health benefit design. Consumer knowledge of new VBD benefits is important to assessing their impact on health care use. Purpose To assess knowledge of features of a VBD. Methods The eligible study population was employees receiving healthcare benefits in an integrated care system in the U.S. Pacific Northwest. In 2010, participants completed a web-based survey 2 months after rollout of the plan, including three true/false questions about benefit design features including copays for preventive care visits and chronic disease medications and premium costs. Analysis was completed in 2012. Knowledgeable was defined as correct response to all three questions; self-reported knowledge was also assessed. Results A total of 3,463 people completed the survey (response rate=71.7%). The majority of respondents were female (80.1%) Caucasians (79.6%) aged 35–64 years (79.0%), reflecting the overall employee population. A total of 45.7% had at least a 4-year college education, and 69.1% were married. About three quarters of respondents correctly answered each individual question; half (52.1%) of respondents answered all three questions correctly. On multivariate analysis, knowledge was independently associated with female gender (OR=1.80, 95% CI=1.40, 2.31); Caucasian race (OR=1.72, 95% CI=1.28, 2.32); increasing household income (OR for ≥$100,000=1.86, 95% CI=1.29, 2.68); nonunion job status (OR compared to union status=1.63, 95% CI=1.17, 2.26); and high satisfaction with the health plan (OR compared to low satisfaction=1.26; 95% CI=1.00, 1.57). Conclusions Incomplete knowledge of benefits is prevalent in an employee population soon after VBD rollout.

Only 63% of the US population aged 50-75 years is adherent with recommended colorectal cancer (CRC) screening guidelines. Efforts are needed to increase screening for CRC.We evaluated a quality improvement intervention conducted in 2010 at Group Health in Washington State to assess the use of interactive voice response (IVR) systems to improve CRC screening. Eligible members were aged 50-81 years, received primary care from a contracted physician, and were due for CRC screening. A total of 13,279 members were identified and randomly assigned to either: (1) an intervention with IVR to encourage CRC screening (n=10,000), or (2) usual care (n=3279). The primary outcome was receipt of any recommended CRC screening test at 6 months postintervention or index date. We used Cox proportional hazards to model time until receipt of CRC screening at 6 months.Adherence to CRC screening was 10.0% in the intervention arm and 7.8% in the usual care arm at 6 months. Randomization to the IVR intervention arm was associated with a 32% increased likelihood of receiving CRC screening (hazard ratio=1.32; 95% confidence interval, 1.14, 1.52) compared with usual care. The difference in CRC screening uptake was apparent by 3 months and persisted for 12 months postintervention (log-rank test, P=0.0012).Our analysis provides "real-world" evidence that IVR is effective when delivered by a commercial health plan, and may be a useful tool for increasing adherence to screening guidelines among patients outside an integrated care practice.

The U.S. Preventive Services Task Force (USPSTF) makes recommendations on which preventive services to routinely incorporate into primary care for specific populations. Behavioral counseling interventions are preventive services designed to help persons engage in healthy behaviors and limit unhealthy ones. The USPSTF's evaluation of behavioral counseling interventions asks 2 primary questions: Do interventions in the clinical setting influence persons to change their behavior, and does changing health behavior improve health outcomes with minimal harms?This article discusses challenges encountered by the USPSTF in aggregating the behavioral counseling intervention literature to develop guidelines. The challenges relate broadly to study populations, intervention protocols, assessment of outcomes, and linking behavior changes to health outcomes. Recommendations to address these challenges include use of the PRECIS (Pragmatic-Explanatory Continuum Indicator Summary) tool as a guide for the development of feasible, replicable, and generalizable behavioral counseling interventions; improved reporting of study methods and results; consensus measures for key behavioral outcomes; and use of existing data sets to link behavior change and clinical outcomes.

Importance Perinatal depression, which is the occurrence of a depressive disorder during pregnancy or following childbirth, affects as many as 1 in 7 women and is one of the most common complications of pregnancy and the postpartum period. It is well established that perinatal depression can result in adverse short- and long-term effects on both the woman and child. Objective To issue a new US Preventive Services Task Force (USPSTF) recommendation on interventions to prevent perinatal depression. Evidence Review The USPSTF reviewed the evidence on the benefits and harms of preventive interventions for perinatal depression in pregnant or postpartum women or their children. The USPSTF reviewed contextual information on the accuracy of tools used to identify women at increased risk of perinatal depression and the most effective timing for preventive interventions. Interventions reviewed included counseling, health system interventions, physical activity, education, supportive interventions, and other behavioral interventions, such as infant sleep training and expressive writing. Pharmacological approaches included the use of nortriptyline, sertraline, and omega-3 fatty acids. Findings The USPSTF found convincing evidence that counseling interventions, such as cognitive behavioral therapy and interpersonal therapy, are effective in preventing perinatal depression. Women with a history of depression, current depressive symptoms, or certain socioeconomic risk factors (eg, low income or young or single parenthood) would benefit from counseling interventions and could be considered at increased risk. The USPSTF found adequate evidence to bound the potential harms of counseling interventions as no greater than small, based on the nature of the intervention and the low likelihood of serious harms. The USPSTF found inadequate evidence to assess the benefits and harms of other noncounseling interventions. The USPSTF concludes with moderate certainty that providing or referring pregnant or postpartum women at increased risk to counseling interventions has a moderate net benefit in preventing perinatal depression. Conclusions and Recommendation The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. (B recommendation)

Editors’ Note: We invited a sample of AJPM’s Editorial Board, supplement guest editors, and longtime colleagues and contributors to share their experiences and impressions of the impact of AJPM on their respective domains. We were particularly fond of Ken Powell’s analogy to being “tenders of the planted seed”—as planters, weeders, and harvesters—watching and nurturing the growth of AJPM, and have elected to lead with his commentary. In the mid-1940s my brothers and I helped our father tend our victory garden. We were suburbanites and our small garden shared a vacant lot with the concrete foundation of a home abandoned in mid-construction during the Depression. We helped plant, weed, and harvest the crops. I especially liked the tall stalks of sweet corn that grew taller than I was. Many years later, in the mid-1990s, I met a couple of other gardeners: Kevin Patrick and Doug Scutchfield visited the Centers for Disease Control (now the Centers for Disease Control and Prevention) to discuss their plans as the editors of the American Journal of Preventive Medicine. I was working in a Branch that was trying to understand the public health importance of regular physical activity, and they had the foresight to know we were planting some seeds in an important new area. I’m not sure that I had even heard of AJPM before their visit. A few years later, while the field of physical activity and public health continued to grow, I shifted my focus to violence and injury prevention. Once again, the team of Patrick and Scutchfield recognized the importance of this topic to the field of preventive medicine. By the turn of the century my work had shifted from the national to the state level. I tried to keep up with the literature by reading or scanning articles as I rode the subway to and from work. The Georgia Division of Public Health had no access to a library so I circulated my personal copy of the American Journal of Preventive Medicine to my team in the Chronic Disease and Injury Epidemiology Section because it contained by far the most articles of interest and practical application for us. Isn’t it interesting to watch things grow. Gardens, journals, and the fields of public health and preventive medicine.

Importance Genital herpes is a prevalent sexually transmitted infection in the United States, occurring in almost 1 in 6 persons aged 14 to 49 years. Infection is caused by 2 subtypes of the herpes simplex virus (HSV), HSV-1 and HSV-2. Antiviral medications may provide symptomatic relief from outbreaks but do not cure HSV infection. Neonatal herpes infection, while uncommon, can result in substantial morbidity and mortality. Objective To update the 2005 US Preventive Services Task Force (USPSTF) recommendation on screening for genital herpes. Evidence Review The USPSTF reviewed the evidence on the accuracy, benefits, and harms of serologic screening for HSV-2 infection in asymptomatic persons, including those who are pregnant, as well as the effectiveness and harms of preventive medications and behavioral counseling interventions to reduce future symptomatic episodes and transmission to others. Findings Based on the natural history of HSV infection, its epidemiology, and the available evidence on the accuracy of serologic screening tests, the USPSTF concluded that the harms outweigh the benefits of serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant. Conclusions and Recommendation The USPSTF recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant. (D recommendation)

Importance Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States, accounting for 1 of every 3 deaths among adults. Objective To update the 2008 US Preventive Services Task Force (USPSTF) recommendation on screening for lipid disorders in adults. Evidence Review The USPSTF reviewed the evidence on the benefits and harms of screening for and treatment of dyslipidemia in adults 21 years and older; the benefits and harms of statin use in reducing CVD events and mortality in adults without a history of CVD events; whether the benefits of statin use vary by subgroup, clinical characteristics, or dosage; and the benefits of various treatment strategies in adults 40 years and older without a history of CVD events. Conclusions and Recommendations The USPSTF recommends initiating use of low- to moderate-dose statins in adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater (B recommendation). The USPSTF recommends that clinicians selectively offer low- to moderate-dose statins to adults aged 40 to 75 years without a history of CVD who have 1 or more CVD risk factors and a calculated 10-year CVD event risk of 7.5% to 10% (C recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use in adults 76 years and older (I statement).

Importance Elevations in levels of total, low-density lipoprotein, and non–high-density lipoprotein cholesterol; lower levels of high-density lipoprotein cholesterol; and, to a lesser extent, elevated triglyceride levels are associated with risk of cardiovascular disease in adults. Objective To update the 2007 US Preventive Services Task Force (USPSTF) recommendation on screening for lipid disorders in children, adolescents, and young adults. Evidence Review The USPSTF reviewed the evidence on screening for lipid disorders in children and adolescents 20 years or younger—1 review focused on screening for heterozygous familial hypercholesterolemia, and 1 review focused on screening for multifactorial dyslipidemia. Findings Evidence on the quantitative difference in diagnostic yield between universal and selective screening approaches, the effectiveness and harms of long-term treatment and the harms of screening, and the association between changes in intermediate outcomes and improvements in adult cardiovascular health outcomes are limited. Therefore, the USPSTF concludes that the balance of benefits and harms cannot be determined. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger. (I statement)

Importance Basal and squamous cell carcinoma are the most common types of cancer in the United States and represent the vast majority of all cases of skin cancer; however, they rarely result in death or substantial morbidity, whereas melanoma skin cancer has notably higher mortality rates. In 2016, an estimated 76 400 US men and women will develop melanoma and 10 100 will die from the disease. Objective To update the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for skin cancer. Evidence Review The USPSTF reviewed the evidence on the effectiveness of screening for skin cancer with a clinical visual skin examination in reducing skin cancer morbidity and mortality and death from any cause; its potential harms, including any harms resulting from associated diagnostic follow-up; its test characteristics when performed by a primary care clinician vs a dermatologist; and whether its use leads to earlier detection of skin cancer compared with usual care. Findings Evidence to assess the net benefit of screening for skin cancer with a clinical visual skin examination is limited. Direct evidence on the effectiveness of screening in reducing melanoma morbidity and mortality is limited to a single fair-quality ecologic study with important methodological limitations. Information on harms is similarly sparse. The potential for harm clearly exists, including a high rate of unnecessary biopsies, possibly resulting in cosmetic or, more rarely, functional adverse effects, and the risk of overdiagnosis and overtreatment. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults (I statement).

The U.S. Preventive Services Task Force (USPSTF) develops evidence-based recommendations about preventive care based on comprehensive systematic reviews of the best available evidence. Decision models provide a complementary, quantitative approach to support the USPSTF as it deliberates about the evidence and develops recommendations for clinical and policy use. This article describes the rationale for using modeling, an approach to selecting topics for modeling, and how modeling may inform recommendations about clinical preventive services. Decision modeling is useful when clinical questions remain about how to target an empirically established clinical preventive service at the individual or program level or when complex determinations of magnitude of net benefit, overall or among important subpopulations, are required. Before deciding whether to use decision modeling, the USPSTF assesses whether the benefits and harms of the preventive service have been established empirically, assesses whether there are key issues about applicability or implementation that modeling could address, and then defines the decision problem and key questions to address through modeling. Decision analyses conducted for the USPSTF are expected to follow best practices for modeling. For chosen topics, the USPSTF assesses the strengths and limitations of the systematically reviewed evidence and the modeling analyses and integrates the results of each to make preventive service recommendations.

Children’s hospitals serve a diverse set of patients, reflecting their dual mission as both community acute care hospitals for children as well as regional centers of excellence for subspecialty care with referrals from far distances. In some parts of the United States, children, such as those living in rural areas, may have to travel scores of miles to reach such specialty hospitals. The concentration of hospital resources in urban and metropolitan areas often forces rural residents to seek specialty and hospital care out of their geographic area, and may result in hospitalizations in freestanding children’s hospitals, nonfreestanding children’s hospitals, or general acute care hospitals. Peltz et al,1 in a study appearing in this month’s Pediatrics , tackle an important question: who are these children who arrive at the doors of freestanding children’s hospitals? What is their risk profile? And how is their utilization characterized? It’s surprising that relatively little is known about these questions given that ∼18% of children live in rural areas. The authors take advantage of a unique source of data, the Pediatric Health Information System database, a proprietary repository of claims and other health information compiled on … Address correspondence to David C. Grossman, MD, MPH, 1730 Minor Ave, Ste 1600, Seattle, WA 98101. E-mail: grossman.d{at}ghc.org

Importance About 14% of US adults aged 40 to 79 years have chronic obstructive pulmonary disease (COPD), and it is the third leading cause of death in the United States. Persons with severe COPD are often unable to participate in normal physical activity due to deterioration of lung function. Objective To update the 2008 US Preventive Services Task Force (USPSTF) recommendation on screening for COPD in asymptomatic adults. Evidence Review The USPSTF reviewed the evidence on whether screening for COPD in asymptomatic adults (those who do not recognize or report respiratory symptoms) improves health outcomes. The USPSTF reviewed the diagnostic accuracy of screening tools (including prescreening questionnaires and spirometry); whether screening for COPD improves the delivery and uptake of targeted preventive services, such as smoking cessation or relevant immunizations; and the possible harms of screening for and treatment of mild to moderate COPD. Findings Similar to 2008, the USPSTF did not find evidence that screening for COPD in asymptomatic persons improves health-related quality of life, morbidity, or mortality. The USPSTF determined that early detection of COPD, before the development of symptoms, does not alter the course of the disease or improve patient outcomes. The USPSTF concludes with moderate certainty that screening for COPD in asymptomatic persons has no net benefit. Conclusions and Recommendation The USPSTF recommends against screening for COPD in asymptomatic adults. (D recommendation)

Description Update of the US Preventive Services Task Force (USPSTF) recommendation on screening for impaired visual acuity in older adults. Methods The USPSTF reviewed the evidence on screening for visual acuity impairment associated with uncorrected refractive error, cataracts, and age-related macular degeneration among adults 65 years or older in the primary care setting; the benefits and harms of screening; the accuracy of screening; and the benefits and harms of treatment of early vision impairment due to uncorrected refractive error, cataracts, and age-related macular degeneration. Population This recommendation applies to asymptomatic adults 65 years or older who do not present to their primary care clinician with vision problems. Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I statement)

* Abbreviations: AAP — : American Academy of Pediatrics USPSTF — : US Preventive Services Task Force When both of us entered pediatrics, we learned that screening dipstick urinalyses was a standard part of well-child care, even though data from at least the 1970s questioned its rationale based on the high false-positive rate and the identification of self-limited disease.1 Screening seemed sensible and innocuous, and neither of us questioned it at the time. Although we were both aware of the debate about benefit, we do not recall hearing about the potential harms of dipstick screening. Over time, the evidence regarding the lack of benefit grew and the recommendation for screening urinalysis was limited to the 5-year-olds2 and then eventually dropped.3 Here is the question: Should a screening test that seems effective be adopted into routine practice with the expectation that evidence would eventually affirm its use or remove it from clinical care? Do we “do first, ask later?” We all know practices in our communities that still routinely use screening urinalyses out of concern about missing a “case” regardless of the potential harm and questionable benefit. How much do we need to know about a preventive screening test before it is recommended as “standard of care?” When do we know enough to either start or stop a service provided to all? How well do we stop a preventive service after it is shown to be ineffective? Preventive care services delivery is the cornerstone of pediatrics. From the newborn visit through adolescence, the American Academy of Pediatrics (AAP) and Bright Futures recommend 31 well-child care visits, each with specific discrete preventive services.4 We are often asked by our trainees in clinic how we decide what services to provide within the limited available time. We were taught by skilled and talented clinicians based on their personal knowledge, experience, and expert opinion about what … Address correspondence to David C. Grossman, MD, MPH, Group Health Cooperative, Group Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101. E-mail: grossman.d{at}ghc.org

This issue includes updated recommendations from the USPSTF on screening mammography for breast cancer. Task Force members discuss the recommendation statement and the strong emerging convergence a...

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.

Few clinical epidemiologic investigations have assessed whether youths exposed to a traumatic injury demonstrate elevations in the full spectrum of provider-recognized psychiatric disorders compared with unexposed, noninjured youths.In a population-based prospective cohort study, data for children and adolescents aged ten to 19 who were enrolled in the Group Health Cooperative health plan were screened for injury visits in the index year of 2001 (N=20,507). Psychiatric diagnoses, including anxiety and acute stress, depressive, substance use, and disruptive behavior disorders, given to these youths over the next three years (2002-2004) were documented, as were psychotropic medication prescriptions. Regression analyses assessed for an independent association between injury and psychiatric disorders and prescription of psychotropic medication.In adjusted regression analyses, injury in the index year was independently associated with significantly increased odds of receiving a diagnosis of anxiety or acute stress (odds ratio [OR]=1.21, 95% confidence interval [CI]=1.02-1.44), depression (OR=1.30, CI=1.10-1.53), and a substance use disorder (OR=1.56, CI=1.21-2.00) and of receiving a psychotropic medication prescription (OR=1.37, CI=1.20-1.57). Youths with traumatic brain injuries also were significantly more likely to receive psychotropic medication prescriptions.Traumatic injury was independently associated with an increased risk of receiving a full spectrum of anxiety, depressive, and substance use diagnoses among youths aged ten to 19. Population-based surveillance procedures that incorporate screening and stepped-care interventions targeting the spectrum of postinjury emotional disturbances have the potential to improve the quality of mental health care for youths treated in general medical settings.