MB: The U.S. Preventive Services Task Force makes recommendations, which AHRQ has traditionally disseminated in print format. Concomitant with developments in the way that clinicians access information, the ePSS was designed to be used by practicing primary care clinicians – nurse practitioners, physicians, and people who teach medical and nursing students. Print media are leisurely and in-depth, and primary care practice these days does not fit in with a schedule like sitting down for 15 minutes to read an article – certainly not while you’re with a patient. We needed to design something that was going to be a handy tool for clinicians.

MB: Members of the U.S. Preventive Services Task Force are from disciplines of internal medicine, family practice, ob/gyn and pediatrics, and they are charged with making recommendations that are evidence-based. While there are certainly a number of bodies that make expert recommendations, the Task Force has been for over 20 years the standard for evidence-based preventive service recommendations. There are currently 110 recommendations for specific populations that cover 59 different preventive service topics. The Task Force uses a framework to examine evidence that balances the benefits of a service against the potential harms of a service, comes up with an assessment of the net benefit for a preventive service, and makes a recommendation that is represented by a letter grade: A and B are recommended preventive services; C is for services for which the net benefit is thought to be so small that they could not make a general recommendation for its use; D is for services that are recommended against; and a grade of I represents no recommendation at all because of insufficient evidence available. We are currently aiming to comply with a standard established by the National Guideline Clearinghouse to update all recommendations every five years. In some cases, five years is actually too long because the medical literature is producing new evidence all the time, and we do have some topics for which we speed up the tempo of review in order to take into account important recent evidence.

The process of vetting the recommendations is rigorous. We work with the Evidence-Based Practice Center, which is a program run out of AHRQ that uses experts in doing syntheses of evidence. They prepare in-depth, systematic reviews of each topic that is going to be considered by the Task Force. The kinds of questions that are looked at by the Task Force would include whether there have been trials of a particular screening test that show that it improves morbidity or mortality. For many screening tests, there is no randomized trial evidence that shows an impact on health, so often what the Task Force and the Evidence-Based Practice Center do is string together sequential questions to determine if there are screening tests that are good in identifying a disease at an earlier stage than it would otherwise be found, and whether earlier discovery can lead to an impact on the outcome. We know that various tests to screen for colorectal cancer, for example, can identify lesions at an earlier stage than if you waited for them to be symptomatic. There are also studies that suggest that treatment of an earlier stage cancer is more likely to be successful than treatment at a late stage.

MB: The ePSS tool is available over the Web, and can be downloaded to be used on a PDA. It works by accessing a database of the Task Force’s recommendations. The Web-based tool can be accessed on the Internet at www.ePSS.ahrq.gov. To download the recommendations to a hand-held device, one needs to use either a Palm operating system version 3.5 or higher, or a Windows device with a PDA operating system called the Microsoft Windows Mobile 5.0 or Microsoft Pocket PC 2002, 2003, or 2003 SE.

MB: Yes, and I would direct you to AHRQ’s National Healthcare Quality Report, which documents what the state of the nation is, in terms of achievement of quality goals. The most recent report, from 2005, shows that for many preventive services, the country is not anywhere near 100 percent coverage. In its companion, the National Healthcare Disparities Report, we see that some of these important services – such as certain cancer screening tests – are underused in populations that are disadvantaged. The National Coalition on Prevention Priorities <www.prevent.org> recently did a health and cost impact analysis of 25 recommended clinical preventive services – to what degree they are being accomplished for the American population, to what degree they could benefit the public, for which services the gap is the largest, and where we could have the most bang for the buck. Colorectal cancer screening is a prime example – its rate is down around 50 percent and has not reached anywhere near the levels of other screening rates. With Pap smear screening for cervical cancer, we’re probably up to 90 percent in many populations, and mammography screening, about 80 percent for many populations. That’s an area where patients and clinicians could be doing better. We donknow the degree to which this is due to clinicians ordering tests, then patients don’t follow through with it. Almost certainly, a good part of it is within the control of the clinician. Discussing aspirin use for people who are at high risk for cardiovascular disease is actually cost-saving: the time spent by the doctor recommending aspirin more than gets made up by the increase in life expectancy if they were successful in talking people into taking it. Tobacco use screening and counseling is also among the highest-ranked in their benefit to cost ratio. In the next tier is colorectal cancer screening, screening for high blood pressure, and screening for cholesterol.

MB: We will be continuously updating the database so that the Website is always current, and when people sign up for the PDA version, they can indicate when they would like to have the newest version uploaded to their PDA. Even the best physicians sometimes forget something, and this tool can remind them about those preventive services that they want to give to their patients. There are also links within the ePSS to further tools. For example, on screening for obesity there is a link to a BMI calculator. The current version of the ePSS is really just the beginning, as we’ve just moved into using an electronic database. At this time, what we have done, mostly, is pasted the paper-based descriptions into our database. But as we update the topics and recommendations, we’ll be providing more electronically-focused tools to maximize the utility of this tool for practicing clinicians.

There are other modalities of the recommendations, each of which continue to serve useful functions. A wall chart version is mostly aimed at consumers – to stimulate conversations between clinicians and patients about some test. A pocket-sized book version is useful for clinical practices that do not have Internet access, or for clinicians who don’t carry PDAs. It’s a handy summary that brings all the recommendations into one place.

MB: You enter the Selector and search for recommendations, which brings you to a screen that has five question categories: age, gender, pregnancy, smoking status and sexual activity. For a 55-year-old smoker who is sexually active, for example, 13 preventive services with either an A or B grade are recommended, 12 with a D grade that are not recommended, one with a C grade, and 21 with an I grade, about which the Task Force is uncertain. You can get more information by clicking for the text of the recommendations. There is also a button for some of these topics that has risk factor information. The first preventive service for the 55-year-old man is aspirin to prevent cardiovascular disease. That’s recommended for adults who are at increased risk, and if you click on the risk information button, it specifies those risk factors, including increasing age, diabetes, elevated cholesterol, high blood pressure, family history.

The beauty of the ePSS on the Web is that a clinician could implement this in their practice in a way that makes sense for them. I’m sure that many clinicians might feel awkward punching up an electronic tool while they’re with a patient, so there are other ways to use it. The person who makes appointments or checks a patient in for their visit could ask these screening questions, input them into the selector tool, print out the page with the recommendations on it and paper clip it to the top of the patient’s chart. Even before the physician walks into the exam room he or she might see the paper on top of the chart that says, "Don’t forget to order the mammogram. Don’t forget to talk about cholesterol."

MB: Absolutely. What we here at AHRQ are committed to doing is disseminating those recommendations and we have several approaches that are under way. We work by partnering with large organizations like the CDC and large insurance companies. The National Business Group on Health is a coalition of corporations that has worked with the CDC and created a National Healthcare Purchaser’s Guide that gives employers specific instructions on how they should construct their health insurance coverage plans so that they cover appropriate preventive services.